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中华肥胖与代谢病电子杂志 ›› 2023, Vol. 09 ›› Issue (04) : 286 -292. doi: 10.3877/cma.j.issn.2095-9605.2023.04.010

综述

肥胖患者术后肺不张的研究进展
王嘉瑞1, 代领傲1, 王晟2,()   
  1. 1. 510630 广州,暨南大学附属第一医院麻醉科
    2. 510630 广州,暨南大学附属第一医院麻醉科;100029 北京,首都医科大学附属北京安贞医院麻醉科
  • 收稿日期:2023-09-20 出版日期:2023-11-30
  • 通信作者: 王晟

Research advances on postoperative atelectasis in patients with obesity

Jiarui Wang1, Lingao Dai1, Shen Wang2,()   

  1. 1. Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou 510630, China
    2. Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou 510630, China; Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
  • Received:2023-09-20 Published:2023-11-30
  • Corresponding author: Shen Wang
引用本文:

王嘉瑞, 代领傲, 王晟. 肥胖患者术后肺不张的研究进展[J]. 中华肥胖与代谢病电子杂志, 2023, 09(04): 286-292.

Jiarui Wang, Lingao Dai, Shen Wang. Research advances on postoperative atelectasis in patients with obesity[J]. Chinese Journal of Obesity and Metabolic Diseases(Electronic Edition), 2023, 09(04): 286-292.

肥胖患者术后肺部并发症(PPCs)的发生率高达18%,其中肺不张是最常见的PPCs,是术中及术后低氧血症的常见原因,也是术后呼吸衰竭和相关死亡的第四大常见原因。大约90%的全麻患者诱导后会发生肺不张,并可能持续至术后数天。肥胖患者因其特殊的病理生理改变使肺不张的持续时间和严重程度进一步增加,导致术后呼吸功能障碍,延缓康复进程。因此认识肺不张的危险因素,及时诊断并实施肺保护性通气策略来预防和治疗术后肺不张对于减少肥胖患者术后肺部并发症尤为重要。本文通过系统阐述肥胖患者的病理生理发生机制及肺不张的诊断、预防及治疗,旨在使临床工作者更加深入了解术后肺不张的发生机制,为临床肥胖患者围手术期肺保护策略提供更多方案,降低肥胖患者术后肺不张的发生率。

The incidence of postoperative pulmonary complications (PPCs) in patients with obesity can arrive at 18%, with atelectasis being the most common PPCs. Atelectasis frequently causes intraoperative and postoperative hypoxemia, and it is the fourth leading cause of postoperative respiratory failure and related mortality. Nearly 90% of patients under general anesthesia experience atelectasis after induction, which can persist for several days postoperatively. The duration and severity of atelectasis are further increased in obese patients due to their unique pathophysiological alterations, leading to postoperative respiratory dysfunction and delayed recovery. Therefore, understanding the risk factors for atelectasis, timely diagnosis, and implementing lung-protective ventilation strategies to prevent and treat postoperative atelectasis is particularly important for reducing PPCs in obese patients. This article systematically explores the pathophysiological mechanisms in obese patients and the diagnosis, prevention, and treatment of atelectasis. It aims to provide clinical practitioners with a deeper understanding of the mechanisms behind postoperative atelectasis, offering more options for perioperative pulmonary protection strategies for obese patients and ultimately reducing the incidence of postoperative atelectasis in this population.

[1]
Rask-Andersen M, Ivansson E, Höglund J, et al. Adiposity and sex-specific cancer risk [J]. Cancer Cell, 2023, 41(6): 1186-1197. e4.
[2]
Cui Y, Cao R, Li G, et al. The effect of lung recruitment maneuvers on post-operative pulmonary complications for patients undergoing general anesthesia: A meta-analysis [J]. PLoS One, 2019, 14(5): e0217405.
[3]
Serin SO, Işıklar A, Karaören G, et al. Atelectasis in Bariatric Surgery: Review Analysis and Key Practical Recommendations [J]. Turk J Anaesthesiol Reanim, 2019, 47(6): 431-438.
[4]
Salome CM, King GG, Berend N. Physiology of obesity and effects on lung function [J]. J Appl Physiol (1985), 2010, 108(1): 206-211.
[5]
Shanmugasundaram K, Bade G, Sampath M, et al. Effect of Obesity on Airway Mechanics [J]. Indian J Endocrinol Metab, 2023, 27(2): 161-166.
[6]
Masa JF, Pépin JL, Borel JC, et al. Obesity hypoventilation syndrome [J]. Eur Respir Rev, 2019, 28(151);180097.
[7]
Hedenstierna G, Edmark L. Mechanisms of atelectasis in the perioperative period [J]. Best Pract Res Clin Anaesthesiol, 2010, 24(2): 157-169.
[8]
Hedenstierna G, Tokics L, Scaramuzzo G, et al. Oxygenation Impairment during Anesthesia: Influence of Age and Body Weight [J]. Anesthesiology, 2019, 131(1): 46-57.
[9]
Suleiman A, Costa E, Santer P, et al. Association between intraoperative tidal volume and postoperative respiratory complications is dependent on respiratory elastance: a retrospective, multicentre cohort study [J]. Br J Anaesth, 2022, 129(2): 263-272.
[10]
Zeng C, Lagier D, Lee J W, et al. Perioperative Pulmonary Atelectasis: Part I. Biology and Mechanisms [J]. Anesthesiology, 2022, 136(1): 181-205.
[11]
Lagier D, Zeng C, Fernandez-Bustamante A, et al. Perioperative Pulmonary Atelectasis: Part II. Clinical Implications [J]. Anesthesiology, 2022, 136(1): 206-236.
[12]
Hedenstierna G, Tokics L, Reinius H, et al. Higher age and obesity limit atelectasis formation during anaesthesia: an analysis of computed tomography data in 243 subjects [J]. Br J Anaesth, 2020, 124(3): 336-344.
[13]
Yu H, Zuo Y, Xu Z, et al. Comparison effects of two muscle relaxant strategies on postoperative pulmonary complications in transapical transcatheter aortic valve implantation: a propensity score-matched analysis [J]. J Cardiothorac Surg, 2023, 18(1): 50.
[14]
Grieco DL, Anzellotti GM, Russo A, et al. Airway Closure during Surgical Pneumoperitoneum in Obese Patients [J]. Anesthesiology, 2019, 131(1): 58-73.
[15]
Chiumello D, Mongodi S, Algieri I, et al. Assessment of Lung Aeration and Recruitment by CT Scan and Ultrasound in Acute Respiratory Distress Syndrome Patients [J]. Crit Care Med, 2018, 46(11): 1761-1768.
[16]
Xie C, Sun K, You Y, et al. Feasibility and efficacy of lung ultrasound to investigate pulmonary complications in patients who developed postoperative Hypoxaemia-a prospective study [J]. BMC Anesthesiol, 2020, 20(1): 220.
[17]
Dransart-Rayé O, Roldi E, Zieleskiewicz L, et al. Lung ultrasound for early diagnosis of postoperative need for ventilatory support: a prospective observational study [J]. Anaesthesia, 2020, 75(2): 202-209.
[18]
Monastesse A, Girard F, Massicotte N, et al. Lung Ultrasonography for the Assessment of Perioperative Atelectasis: A Pilot Feasibility Study [J]. Anesth Analg, 2017, 124(2): 494-504.
[19]
Yu X, Zhai Z, Zhao Y, et al. Performance of Lung Ultrasound in Detecting Peri-Operative Atelectasis after General Anesthesia [J]. Ultrasound Med Biol, 2016, 42(12): 2775-2784.
[20]
Frerichs I, Amato MB, van Kaam AH, et al. Chest electrical impedance tomography examination, data analysis, terminology, clinical use and recommendations: consensus statement of the TRanslational EIT developmeNt stuDy group [J]. Thorax, 2017, 72(1): 83-93.
[21]
Sella N, Pettenuzzo T, Zarantonello F, et al. Electrical impedance tomography: A compass for the safe route to optimal PEEP [J]. Respir Med, 2021, 187: 106555.
[22]
Hochhausen N, Kapell T, Dürbaum M, et al. Monitoring postoperative lung recovery using electrical impedance tomography in post anesthesia care unit: an observational study [J]. J Clin Monit Comput, 2022, 36(4): 1205-1212.
[23]
Sümer I, Topuz U, Alver S, et al. Effect of the "Recruitment" Maneuver on Respiratory Mechanics in Laparoscopic Sleeve Gastrectomy Surgery [J]. Obes Surg, 2020, 30(7): 2684-2692.
[24]
Sameed M, Choi H, Auron M, et al. Preoperative Pulmonary Risk Assessment [J]. Respir Care, 2021, 66(7): 1150-1166.
[25]
Azhar N. Pre-operative optimisation of lung function [J]. Indian J Anaesth, 2015, 59(9): 550-556.
[26]
Nestler C, Simon P, Petroff D, et al. Individualized positive end-expiratory pressure in obese patients during general anaesthesia: a randomized controlled clinical trial using electrical impedance tomography [J]. Br J Anaesth, 2017, 119(6): 1194-1205.
[27]
Pereira SM, Tucci MR, Morais CCA, et al. Individual Positive End-expiratory Pressure Settings Optimize Intraoperative Mechanical Ventilation and Reduce Postoperative Atelectasis [J]. Anesthesiology, 2018, 129(6): 1070-1081.
[28]
中华医学会麻醉学分会"围术期肺保护性通气策略临床应用专家共识"工作小组. 围术期肺保护性通气策略临床应用专家共识 [J]. 中华麻醉学杂志, 2020, 40(05) : 513.
[29]
Yang D, Grant MC, Stone A, et al. A Meta-analysis of Intraoperative Ventilation Strategies to Prevent Pulmonary Complications: Is Low Tidal Volume Alone Sufficient to Protect Healthy Lungs? [J]. Ann Surg, 2016, 263(5): 881-887.
[30]
Wiegert S, Greco F, Baumann P, et al. Impact of high tidal volume ventilation on surfactant metabolism and lung injury in infant rats [J]. Am J Physiol Lung Cell Mol Physiol, 2020, 319(3): L562- L575.
[31]
Serpa Neto A, Hemmes SN, Barbas CS, et al. Protective versus Conventional Ventilation for Surgery: A Systematic Review and Individual Patient Data Meta-analysis [J]. Anesthesiology, 2015, 123(1): 66-78.
[32]
Kim BR, Lee S, Bae H, et al. Lung ultrasound score to determine the effect of fraction inspired oxygen during alveolar recruitment on absorption atelectasis in laparoscopic surgery: a randomized controlled trial [J]. BMC Anesthesiol, 2020, 20(1): 173.
[33]
Edmark L, Kostova-Aherdan K, Enlund M, et al. Optimal oxygen concentration during induction of general anesthesia [J]. Anesthesiology, 2003, 98(1): 28-33.
[34]
Balonov K. Intraoperative protective lung ventilation strategies in patients with morbid obesity [J]. Saudi J Anaesth, 2022, 16(3): 327-331.
[35]
孟香弟, 黄晶晶, 王涛, 等. 吸入氧浓度对行腹腔镜胃减容术的病态肥胖患者肺氧合和呼吸力学的影响 [M]. 国际麻醉学与复苏杂志, 2020, 41(05): 469.
[36]
Zhu C, Yao J W, An LX, et al. Effects of intraoperative individualized PEEP on postoperative atelectasis in obese patients: study protocol for a prospective randomized controlled trial [J]. Trials, 2020, 21(1): 618.
[37]
Girrbach F, Petroff D, Schulz S, et al. Individualised positive end-expiratory pressure guided by electrical impedance tomography for robot-assisted laparoscopic radical prostatectomy: a prospective, randomised controlled clinical trial [J]. Br J Anaesth, 2020, 125(3): 373-382.
[38]
Mercado P, Maizel J, Kontar L, et al. Moderate and Severe Acute Respiratory Distress Syndrome: Hemodynamic and Cardiac Effects of an Open Lung Strategy With Recruitment Maneuver Analyzed Using Echocardiography [J]. Crit Care Med, 2018, 46(10): 1608-1616.
[39]
Young CC, Harris EM, Vacchiano C, et al. Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations [J]. Br J Anaesth, 2019, 123(6): 898-913.
[40]
Pei S, Wei W, Yang K, et al. Recruitment Maneuver to Reduce Postoperative Pulmonary Complications after Laparoscopic Abdominal Surgery: A Systematic Review and Meta-Analysis [J]. J Clin Med, 2022, 11(19):5841.
[41]
吴觉伦, 申乐. 肥胖患者围术期肺保护性通气策略的研究进展 [M]. 中华麻醉学杂志, 2023, 43(02): 244-248.
[42]
Rothen HU, Sporre B, Engberg G, et al. Re-expansion of atelectasis during general anaesthesia: a computed tomography study [J]. Br J Anaesth, 1993, 71(6): 788-795.
[43]
Seyni-Boureima R, Zhang Z, Antoine M, et al. A review on the anesthetic management of obese patients undergoing surgery [J]. BMC Anesthesiol, 2022, 22(1): 98.
[44]
Sevdi MS, Demirgan S, Erkalp K, et al. Comparison of Intra-operative Pressure-Controlled Ventilation and Volume-Controlled Ventilation in Bariatric Surgery: A Prospective Randomized Study [J]. Cureus, 2021, 13(8): e17567.
[45]
Lee YY, Han JI, Kang BK, et al. Assessment of Perioperative Atelectasis Using Lung Ultrasonography in Patients Undergoing Pneumoperitoneum Surgery in the Trendelenburg Position: Aspects of Differences according to Ventilatory Mode [J]. J Korean Med Sci, 2021, 36(50): e334.
[46]
Bagchi A, Rudolph MI, Ng PY, et al. The association of postoperative pulmonary complications in 109,360 patients with pressure-controlled or volume-controlled ventilation [J]. Anaesthesia, 2017, 72(11): 1334-1343.
[47]
Wang C, Zhao N, Wang W, et al. Intraoperative mechanical ventilation strategies for obese patients: a systematic review and network meta-analysis [J]. Obes Rev, 2015, 16(6): 508-517.
[48]
Wang J, Zeng J, Zhang C, et al. Optimized ventilation strategy for surgery on patients with obesity from the perspective of lung protection: A network meta-analysis [J]. Front Immunol, 2022, 13: 1032783.
[49]
Toker MK, Altıparmak B, Uysal A, et al. [Comparison of pressure-controlled volume-guaranteed ventilation and volume-controlled ventilation in obese patients during gynecologic laparoscopic surgery in the Trendelenburg position] [J]. Braz J Anesthesiol, 2019, 69(6): 553-560.
[50]
Fernandez-Bustamante A, Hashimoto S, Serpa Neto A, et al. Perioperative lung protective ventilation in obese patients [J]. BMC Anesthesiol, 2015, 15: 56.
[51]
Gad M, Gaballa K, Abdallah A, et al. Pressure-Controlled Ventilation with Volume Guarantee Compared to Volume-Controlled Ventilation with Equal Ratio in Obese Patients Undergoing Laparoscopic Hysterectomy [J]. Anesth Essays Res, 2019, 13(2): 347-353.
[52]
Ireland CJ, Chapman TM, Mathew SF, et al. Continuous positive airway pressure (CPAP) during the postoperative period for prevention of postoperative morbidity and mortality following major abdominal surgery [J]. Cochrane Database Syst Rev, 2014, 2014(8): Cd008930.
[53]
Herzberg J, Guraya SY, Merkle D, et al. The role of prophylactic administration of CPAP in general surgical wards after open visceral surgery in reducing postoperative pneumonia-a retrospective cohort study [J]. Langenbecks Arch Surg, 2023, 408(1): 167.
[54]
Baltieri L, Santos LA, Rasera I, Jr., et al. Use of positive pressure in the bariatric surgery and effects on pulmonary function and prevalence of atelectasis: randomized and blinded clinical trial [J]. Arq Bras Cir Dig, 2014, 27 Suppl 1(Suppl 1): 26-30.
[55]
Odor PM, Bampoe S, Gilhooly D, et al. Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis [J]. BMJ, 2020, 368: m540.
[56]
Casati A, Comotti L, Tommasino C, et al. Effects of pneumoperitoneum and reverse Trendelenburg position on cardiopulmonary function in morbidly obese patients receiving laparoscopic gastric banding. Eur J Anaesthesiol. 2000 May;17(5):300-305.
[57]
Shi ZG, Geng WM, Gao GK, et al. Application of alveolar recruitment strategy and positive end-expiratory pressure combined with autoflow in the one-lung ventilation during thoracic surgery in obese patients [J]. J Thorac Dis, 2019, 11(2): 488-494.
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