保护性通气策略对老年人术中肺顺应性及氧合的影响

目的研究保护性通气策略[低潮气量(LV)加机械通气(PEEP)]对老年人术中肺顺应性(CL)及氧合的影响。方法选在气管插管全身麻醉下实施择期开腹手术的老年患者60例(ASAⅠ～Ⅱ级,年龄60～81岁),随机分为(1)LV组:VT(潮气量)为7 ml/kg PBW(预测体重);(2)LV+PEEP组:VT为7ml/kgPBW,PEEP为5 cmH_2O;(3)C组(常规通气量组):VT为12 ml/kg PBW。分别于插管后5 min(TO)、30 min(T1)、1 h(T2)、3 h(T3)4个时点记录心搏率(HR)、平均动脉压(MAP)、血氧饱和度(SpO_2)、呼气末二氧化碳分压(P_(ET)CO_2)、气道峰压(Ppeak)、气道平台压(Pplat)及CL变化,并于各时点桡动脉处抽血测血气指标。结果三组患者各时点HR、MAP、SpO_2、P_(ET)CO_2及手术种类比较差异无统计学意义(P0.05);C组在机械通气期间Pplat、Ppeak明显高于LV组(P=0.001;P=0.012)及LV+PEEP组(P=0.006;P=0.011);LV组、LV+PEEP组、C组CL均随着时间延长呈下降趋势(P=0.003;P=0.001;P=0.000),C组明显低于LV组与LV+PEEP组(P=0.004;P=0.001);LV组与LV+PEEP组差异无统计学意义(P=0.340)。动脉血氧分压(PaO_2)在LV组、LV+PEEP组、C组均随着时间延长呈下降趋势((P=0.002;P=0.002;P=0.000),C组较LV组与ILV+PEEP组降低明显(P=0.001;P=0.001),LV组与LV+PEEP组差异无统计学意义(P=0.231)。结论与常规大潮气量相比,小潮气量通气(7 m/kg PBW)能改善老年人术中的氧合及肺顺应性;小PEEP未显示出进一步的肺保护作用。     

低潮气量通气对老年腹部手术肺顺应性及氧合的影响

目的研究低潮气量通气对老年人术巾肺顺应性（CL）及氧合的影响。方法40例60岁以上、ASAI或Ⅱ级老年患者,在气管插管全身麻醉下实施择期开腹手术。观察组潮气量（VT）为7ml／kg预测体质量（PBW）;对照组VT为12ml／kgPBW。分别于插管后5min（T0）、30min（T1）、1h（T2）、3h（T3）4个时点记录心率（HR）、平均动脉压（MAP）、血氧饱和度（SpO2）、呼气末二氧化碳分压（PETCO2）、气道峰压（Ppeak）、气道平台压（Pplat）、CL;并于各时点桡动脉处抽血测血气指标。结果对照组在机械通气期间,Ppeak、Pplat明显高于观察组（P=0．012,P=0．013）;两组CL均随着时间延长呈下降趋势,对照组低于观察组（P=0．012）;对照组T3时点PaO2低于观察组（P〈0．05）。结论低潮气量通气改善了老年人术中的氧合及CL,能减轻机械通气造成的肺损伤。     

Dynamic nomogram for long-term survival in patients with non-small cell lung cancer after pneumonectomy

BackgroundThe study aims to identify prognostic factors of overall survival (OS) in patients who had pneumonectomy, in order to develop a practical dynamic nomogram model.MethodsA total of 2,255 patients with non-small cell lung cancer (NSCLC) who underwent pneumonectomy were identified from 2010–2015 in the Surveillance, Epidemiology, and End Results (SEER) database. The cohort was divided into a training (2011–2015) and a validation [2010] cohort. A nomogram and a risk classification system were constructed from the independent survival factors in multivariable analysis. The predictive accuracy of the nomogram was measured through internal and external validation.ResultsIndependent prognostic factors associated with OS were gender, age, pathology, tumor size, N stage, chemotherapy, and radiotherapy. The C-index of the nomogram for OS was 0.675 (95% CI: 0.655–0.694). Similarly, the AUC of the model was 0.733, 0.709, and 0.701 for the 1-, 3-, and 5-year OS, respectively. The calibration curves for survival demonstrated good agreement. Significant statistical differences were found in the OS of patients within different risk groups. An online calculation tool was established for clinical use.ConclusionsThis novel nomogram was able to provide a reliable prognosis for survival in patients with NSCLC undergoing pneumonectomy.     

Quantitative lung scintigrams and lung function in the selection of patients for pneumonectomy

A method for predicting postoperative respiratory function following lung resection has been used in 11 patients with both histologically proven bronchial carcinoma and chronic obstructive airways disease, in order to assess their fitness for surgical treatment. Quantitative ventilation and perfusion scintigrams were used to measure the amount of functioning tissue in each lung. These data were used in conjunction with spirometric measurements to calculate the likely functional effect of pneumonectomy. There was a high degree of correlation (r) between predicted and measured lung function for both FEV1 (r = 0.75, P less than 0.01) and FVC (r = 0.88, P less than 0.01). The postoperative FEV1 was within 150 ml of the predicted value in 45% of the patients. In the remaining patients the actual volumes were greater than predicted by 210-540 ml. For FVC the results were within 150 ml of predicted in 45% of patients and in the remainder actual volumes were greater by 160-650 ml. Both sets of calculations underestimated lung volumes by an average of 200 ml. The method is shown to be accurate, simple, non-invasive, and readily available and brings a degree of objectivity to an important decision that is often based mainly on clinical assessment.     

Indirect assessment of lung compliance in chronic lung diseases

The slope of the flow volume curves was analysed in 20 normal subjects 28 patients with irreversible chronic airway obstruction, 24 patients with bronchial asthma, 8 patients with diffuse interstitial fibrosis and 7 patients with extensive bronchiectasis. Time constant of the system was taken as the slope of the curve between 50 and 25% of the vital capacity. When considered along with plethysmographically obtained airway resistance, an indirect estimate of the lung compliance was obtained. Significant differences in the estimated lung compliance in the normal subjects, patients with obstructive lung disease or diffuse interstitial fibrosis were demonstrated.     

Compensatory growth of the lung following partial pneumonectomy

In a variety of species, partial resection of the lung initiates rapid compensatory growth of the remaining tissue adequate to restore normal total lung mass. Increases in tissue content of protein, RNA, and DNA in proportion to dry lung weight suggest hyperplastic growth of the tissue, rather than cellular hypertrophy. A general acceleration of cell division is supported further by the results of quantitative morphometric studies, which indicate that both cellular and functional characteristics of the peripheral lung, including alveolar and capillary volumes and thickness and surface area of the blood-gas barrier, are maintained when compensatory growth is complete. The rate and nature of the growth response are subject to hormonal modulation, particularly by adrenal steroids and growth hormone. Little is known, however, regarding the specific actions of these agents or of additional factors that may be primary regulators of the initiation and cessation of accelerated compensatory growth. Definition of such regulatory mechanisms is of critical importance in understanding normal growth and development of the lung and the response of the lung to injury, as well as in future efforts to manipulate growth and/or repair of the tissue.     

Influence of maternal pneumonectomy on fetal lung growth

This study was conducted to test the hypothesis that the compensatory growth of the maternal lung during pregnancy influences fetal lung growth, specifically the fetal lung DNA content. A left pneumonectomy (PN) was performed in pregnant albino rats at different gestation days (GD 3, 7, 9, 10, 12, 14, 16 and 18) and the rats sacrificed at GD 21. Only mothers with litter size of 9-14 fetuses were used for this study. Maternal lung growth was assessed by measuring lung weight, lung air volume and lung DNA content, and the fetal lung growth by lung DNA content. The findings were: (1) pregnancy did not influence the rate of compensatory growth of the remaining lung following PN; (2) neither thoracotomy nor PN had any effect on placental weight or DNA content; (3) lung DNA content for body weight was larger in fetuses of PN rats when PN was performed in the first half of gestation; (4) there was a direct relationship between DNA content of the fetal lung and maternal lung in PN rats; and (5) neither thoracotomy nor PN in pregnant rats influenced the maturation of the fetal lung. The results suggest that a growth factor(s), specific for lungs, is released into maternal circulation following PN, crosses the placenta and enhances the fetal lung growth without affecting its maturation.     

Postoperative atrial fibrillation in pneumonectomy for primary lung cancer

BackgroundThis study assessed the incidence and risk factors (RFs) of postoperative atrial fibrillation (POAF) and its impact on clinical outcomes in patients undergoing pneumonectomy for lung cancer.MethodsBetween 2013 and 2018, this monocentric retrospective study enrolled 324 consecutive pneumonectomy patients for primary lung cancer from our institution and 350 lobectomy and 349 segmentectomy cases matched by age, sex and body mass index (BMI). RF for POAF and postoperative death in pneumonectomy patients were assessed by logistic regression, and long-term outcomes after a median follow-up of 30 (range, 2–61) months by Cox proportional hazard model. Electrophysiology study (EPS) files of 30 AF patients with lung resection history were reviewed.ResultsPOAF developed more often after pneumonectomy than lobectomy and segmentectomy (23.2% vs. 6.6% vs. 1.4%, respectively; P<0.001). Among 75 pneumonectomy patients with POAF, POAF was solitary in 55 patients (73.3%) and concurrent with other complications in 3 patients (4%). POAF risk after pneumonectomy was 4 and 22 times that after lobectomy and segmentectomy, respectively, with age >60 years and left atrial diameter (LAd) ≥35 mm as independent predictors. POAF, infection and hemorrhage were independent RFs for perioperative death after pneumonectomy; however, POAF was not RF for long-term death. Pulmonary vein (PV) trigger was identified in 60% (18/30) of AF patients with lung resection history, with stump PVs being more active than non-stump PVs (38.2% vs. 10.5%, P<0.001).ConclusionsPost-pneumonectomy AF, with remarkable incidence, risk and independent predictors including age >60 years and LAd ≥35 mm, was mostly solitary and possibly secondary to stump and non-stump PV triggers. POAF, along with infection and hemorrhage, was a RF for perioperative death.     

Compensatory growth of residual lung after pneumonectomy in childhood]

Though pneumonectomy proved to be a potent stimulus to compensatory growth in the animal model, the literature on this subject in human patients is sparse. We report a rare case of compensatory growth after pneumonectomy in childhood. A 17-year-old man was admitted to our hospital because of chest pain. He had been capable of normal exercise despite a history of pneumonectomy at the age of 4. Chest radiography showed pneumothorax and a displaced heart. In a chest CT scan, both pleural spaces were filled with the enlarged left lung. Since thoracoscopic examination showed a bulla at the surface of S3, bullectomy was performed. The specimen resected from the lung showed slight dilatation of the alveoli. It is considered that the enlargement of the residual lung had occurred as a result of alveolar multiplication rather than by dilatation of the existing alveoli. This case demonstrates lung regeneration in childhood.     

老年肺癌全肺切除术的围手术期处理

目的探讨全肺切除术对≥60岁老年肺癌患者的影响、手术适应证和围手术期管理。方法对47例≥60岁行全肺切除术肺癌患者进行回顾分析。结果术后并发心律失常28例,肺部炎症4例,呼吸衰竭3例,支气管胸膜瘘1例,经对症治疗后均好转。本组47例无围手术期死亡。结论≥60岁老年肺癌患者行全肺切除术有较大的风险,要根据肺功能状态和病变范围并结合血气分析、心脏功能等因素综合分析,合理选择适应证和术式,并重视围手术期管理。经充分准备,部分老年患者能进行全肺切除术。     

肺癌全肺切除655例临床分析

目的探讨全肺切除术在中晚期肺癌治疗中的作用。方法对1994年10月—2003年11月行全肺切除术的655例肺癌病例进行回顾性分析。结果全组1、3、5年生存率为88.0%、50.9%、24.1%。按照TNM分期5年生存率:Ⅰa期37.0%,Ⅰb期40.6%,Ⅱa期0%,Ⅱb期37.9%,Ⅲa期19.3%,Ⅲb期7.0%,Ⅳ期17.7%。不同病理类型5年生存率:非小细胞癌24.5%,小细胞癌22.0%。术后死亡率和并发症率分别为2.4%和10.4%。结论全肺切除术有可接受的术后死亡率和并发症率,在严格掌握手术适应症的基础上,术中操作熟练规范,重视围手术期的观察和处理,全肺切除术对于治疗中、晚期肺癌仍不失为一种有效的方法。     

Neoadjuvant chemotherapy and pneumonectomy in a lung cancer patient on hemodialysis

Major pulmonary resections are rarely performed in non-small cell lung cancer patients on hemodialysis. To date only two cases of pneumonectomy performed in such patients are reported in the literature. Moreover, chemotherapy, as a treatment for advanced non-small cell lung cancer, is not routinely administered to patients with end-stage renal disease requiring hemodialysis. We present the case of a stage IIIB non-small cell lung cancer patient on hemodialysis who successfully underwent neoadjuvant chemotherapy followed by pneumonectomy. To our knowledge, this is the first case of non-small cell lung cancer patient on hemodialysis reported in the literature who successfully underwent this type of combined therapy.     

Morphological changes accompanying compensatory lung growth after pneumonectomy in rats

To elucidate morphological change of alveoli in compensatory lung growth, left pneumonectomy was performed on male 4 weeks-old rats (Fischer-344) and light microscopic morphometry, scanning electron microscopic study and histochemistry using anti-bromodeoxyuridine were made. The wet lung weight and lung volume of the residual lungs in the pneumonectomized rats reached the same as those of sham operated rats at one and two weeks after the operation, respectively. From the data concerning the mean linear intercept in the cardiac lobe of the pneumonectomized rats, alveoli of two different sizes were observed, suggesting that the compensatory lung growth in the alveoli may take two steps or at least two different sizes of alveoli may exist mixed together. The data of histochemistry suggest that in pneumonectomized rats the alveoli beneath the pleura (less than 2 mm) included an increased number of S phase cells compared with those of deeper areas. From these morphological changes in the lungs of the pneumonectomized rats it is possible to suggest a hypothesis that stretch stimulation is the first trigger in compensatory lung growth.     

Normal lung growth and response after pneumonectomy in rats at various ages

Lung growth was accompanied by alveolar multiplication in rats from 4 to 10 wk of age; the multiplication then ceased until 14 wk of age, and in this latter interval the alveolar walls appeared to lengthen. The relationship between size of surface alveoli and size of internal alveoli of the lower lobe changed with age, and the relationship was not altered by pneumonectomy. The surface alveoli were smaller than internal alveoli at 4 wk of age, the same size at 6 and 10 wk of age, and larger at 14 wk of age. Four-week-old rats responded to pneumonectomy with an increase in size of the contralateral lung and an increase in the number of alveoli. Direct alveolar counts did not show a significant increase in number of alveoli after pneumonectomy in 8- and 12-wk-old rats. the alveolar surface area incresed almost directly with the increase in gas-exchanging lung volume in 8-wk-old rats, suggesting that alveolar multiplication might have occurred. In 12-wk-old rats, however, the alveolar surface area increased to the 0.71 power of the increase in gas-exchanging lung volume, suggesting that alveolar enlargement, rather than alveolar multiplication, had occurred. Taken in conjunction with the data for growth in normal and sham-operated animals, these results suggest that compensatory alveolar multiplication is part of the adaptive response to pneumonectomy when this operation is performed at a time at which alveolar multiplication normally occurs. When pneumonectomy is performed after alveolar multiplication has ceased, the adaptive response is primarily one of air-space enlargement. Lung volume, weight, surface area, and protein responses to pneumonectomy were smaller at 12 wek of age than at 4 and 8 wk of age.     

The events in the contralateral lung following pneumonectomy in the rabbit

Growth of the contralateral lung was studied over a period of 21 days following pneumonectomy in 10-week-old rabbits. Lung volume and lung protein were increased on day 5, and lung weight was increased on day 7 after pneumonectomy. Synthesis of deoxyribonucleic acid (DNA) in the cells of the alveolar wall, as assessed autoradiographically, was first significantly increased on day 5, reached a peak on day 11, and had declined to control level by day 21. Synthesis of DNA also increased significantly in airway epithelial cells between days 5 and 11 with a peak on day 7, but the increase was less marked than in the alveolar wall. The amount of DNA in the lung increased significantly by day 9, and the increment in DNA was about that anticipated from autoradiography. It seems that maximum compensatory lung growth occurs in the second week following pneumonectomy in the rabbit and is complete in 3 weeks. The compensatory growth involves proliferation of both parenchymal and non-parenchymal cells in the alveolar wall.     

Preventive diaphragm plasty after pneumonectomy on account of lung cancer

Experience is presented of 53 cases of diaphragm plasty of the bronchial stump, tracheobronchial anastomosis, pericardium, and esophagus wall after extended pneumonectomy on account of lung cancer. A pedicled diaphragm flap was used to prevent bronchopleural fistula in 53 patients, as well as heart dislocation after wide resection of the pericardium in 26, and esophagopleural fistula after resection of the muscle coat of the esophagus in 2. In all cases, there was a high risk of these complications. Dehiscence of the bronchial stump or tracheobronchial anastomosis occurred in 9 patients, but due to diaphragm plasty, a bronchopleural fistula formed in only 3. Restoration of the pericardium and the esophageal muscle coat was successful in all cases. Overall morbidity was 22.6%, 30-day mortality was 7.5%, hospital mortality was 11.3%. Causes of death were fulminant pneumonia of the single lung, cerebral hemorrhage, pulmonary embolism, heart failure, early tumor progression, and sepsis, in one case each. The results were compared with those in 49 patients who underwent other methods of bronchial stump or tracheobronchial anastomosis reinforcement. The analysis revealed that the diaphragm flap was highly efficacious as a multipurpose plastic material.     

全肺切除治疗低肺功能肺结核毁损肺患者的临床研究

目的探讨全肺切除治疗低肺功能肺结核毁损肺患者的临床应用价值。方法选择低肺功能肺结核毁损肺患者36例,所有患者均选择全肺切除术,其中左侧全肺切除19例,右侧全肺切除17例,术前及术后应用抗结核药物。观察患者治疗后的治愈率、肺结核转阴率、并发症发生情况及死亡率。比较患者术前、术后3、6个月肺功能情况。结果临床治愈35例,治愈率97.22%。术前痰培养阳性36例,术后痰培养阴性34例,转阴率为94.44%。术后患者肺功能逐渐改善,与术前相比,患者术后3个月及6个月FEV1、MVV水平均逐渐升高,其差异均具有统计学意义(P<0.05)。结论全肺切除在选择性低肺功能肺结核毁损肺患者的治疗中具有很高临床应用价值。