[1]李静 沈骁 孙加奎 孙芳 薛寅莹 章文豪 章淬.急性Stanford A型主动脉夹层术后膈肌功能障碍的临床研究[J].心血管病学进展,2022,(7):657-661.[doi:10.16806/j.cnki.issn.1004-3934.2022.07.000]
 LI Jing,SHEN Xiao,SUN Jiakui,et al.Clinical Study of Diaphragmatic Dysfunction After Surgical Treatment of Acute Stanford Type A Aortic Dissection[J].Advances in Cardiovascular Diseases,2022,(7):657-661.[doi:10.16806/j.cnki.issn.1004-3934.2022.07.000]
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急性Stanford A型主动脉夹层术后膈肌功能障碍的临床研究()
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《心血管病学进展》[ISSN:51-1187/R/CN:1004-3934]

卷:
期数:
2022年7期
页码:
657-661
栏目:
论著
出版日期:
2022-07-25

文章信息/Info

Title:
Clinical Study of Diaphragmatic Dysfunction After Surgical Treatment of Acute Stanford Type A Aortic Dissection
文章编号:
202201053
作者:
李静 沈骁 孙加奎 孙芳 薛寅莹 章文豪 章淬
(南京医科大学附属南京医院(南京市第一医院)
Author(s):
LI JingSHEN XiaoSUN JiakuiSUN FangXUE YinyingZHANG WenhaoZHANG Cui
(Department of Intensive Care Unit,Nanjing First Hospital,Nanjing Medical University,Nanjing 210006,Jiangsu,China)
关键词:
膈肌急性Stanford A型主动脉夹层超声
Keywords:
DiaphragmAcute Stanford type A aortic dissectionUltrasound
DOI:
10.16806/j.cnki.issn.1004-3934.2022.07.000
摘要:
目的 明确急性Stanford A型主动脉夹层(ATAAD)术后合并心功能不全的患者中膈肌功能障碍的发生情况及其对呼吸机撤机的影响。方法 采用前瞻性研究,入选2019年1月—2021年9月入住南京医科大学附属南京医院行孙氏手术且合并心功能不全(左室射血分数<55%)的ATAAD患者43例,术后应用床旁超声测定膈肌增厚率(DTF)及膈肌移动度,根据DTF分为膈肌功能正常组及障碍组,观察对比两组患者基线资料、手术相关指标及机械通气相关临床预后等指标。结果 纳入研究的ATAAD患者中膈肌功能障碍(DTF<20%)29例,发生率为67.4%(29/43)。与正常组相比,障碍组平均DTF明显小于正常组(P<0.001),平静呼气末移动度及最大呼气末移动度均小于正常组(P<0.001)。两组患者术后LVEF及正性肌力药物的应用情况均无统计学差异。与膈肌功能正常组相比,障碍组主动脉阻断时间(P=0.001)及体外循环时间(P=0.002)更长,而两组之间的手术时间无明显差异,膈肌功能障碍组的机械通气时间较正常组延长(P<0.001),且住ICU时间也明显延长(P=0.011)。拔管后无创辅助通气的比例、再次气管插管的比例及行气管切开术的比例,两组之间均无统计学差异。结论 膈肌功能障碍在ATAAD术后合并左心功能不全的患者中发生普遍,且与机械通气时间、住ICU时间相关,以超声评价其膈肌功能简便可行,并对术后撤机具有预测及指导价值。
Abstract:
Objective To investigate the occurrence of diaphragmatic dysfunction in patients with cardiac insufficiency after acute Stanford type A aortic dissection(ATAAD) and its impact on ventilator weaning. Methods In this prospective study,43 ATAAD patients with cardiac insufficiency(left ventricular ejection fraction<55%) who were admitted to Nanjing First Hospital from January 2019 to September 2021 underwent Sun’s surgery were enrolled. Diaphragmatic thickening fraction(DTF) and diaphragmatic mobility were measured by bedside ultrasound. According to DTF,the patients were divided into normal diaphragmatic function group and diaphragmatic dysfunction group. The baseline data,surgical indicators and clinical prognostic indicators related to mechanical ventilation were observed and compared between the two groups. Results A total of 43 ATAAD patients were included in the study,including 29 patients with diaphragmatic dysfunction(DTF<20%),the incidence was 67.4%(29/43). Compared with normal diaphragm function group,the mean DTF of diaphragmatic dysfunction group was significantly lower than normal group(P<0.001),and calm end-expiratory mobility and the maximum end-expiratory mobility were both significantly lower than normal group(P<0.001). There was no statistical difference in the LVEF and the application of positive inotropic drugs between the two groups. Compared with normal diaphragm function group,the time to aorta occlusion(P=0.001) and the time to cardiopulmonary bypass(P=0.002) were longer,but there was no significant difference in the operation time between the two groups. The duration of mechanical ventilation was longer in the diaphragmatic dysfunction group than in the normal group(P<0.001). The ICU length of stay in the diaphragmatic dysfunction group was also longer than that in normal diaphragm function group(P=0.011). There was no statistical difference between the two groups in the proportion of non-invasive ventilation,reintubation and tracheotomy after extubation. Conclusion Diaphragmatic dysfunction is common in patients with left cardiac insufficiency after acute Stanford type A aortic dissection,and it is related to the duration of mechanical ventilation and the ICU length of stay. It is simple and feasible to evaluate diaphragmatic function by ultrasound,and it plays a predictive and guiding role in postoperative ventilator weaning.

参考文献/References:

[1] Pape LA,Awais M,Woznicki EM. Presentation,diagnosis,and outcomes of acute aortic dissection:seventeen-year trends from the international registry of acute aortic dissection[J]. J Vasc Surg,2016,63(2):552-553.
[2] Erbel R,Aboyans V,Boileau C,et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases:document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the European Society of Cardiology(ESC)[J]. Eur Heart J,2014,35(41):2873-2926.
[3] Aguirre VJ,Sinha P,Zimmet A,et al. Phrenic nerve injury during cardiac surgery:mechanisms,management and prevention[J]. Heart Lung Circ,2013,22(11):895-902.
[4] Lerolle N,Guérot E,Dimassi S,et al. Ultrasonographic diagnostic criterion for severe diaphragmatic dysfunction after cardiac surgery[J]. Chest,2009,135(2):401-407.
[5] Tang H,Shrager JB. The signaling network resulting in ventilator-induced diaphragm dysfunction[J]. Am J Respir Cell Mol Biol,2018,59(4):417-427.
[6] Zakkar M,Guida G,Suleiman MS,et al. Cardiopulmonary bypass and oxidative stress[J]. Oxid Med Cell Longev,2015,2015:189863.
[7] Moury PH,Cuisinier A,Durand M,et al. Diaphragm thickening in cardiac surgery:a perioperative prospective ultrasound study[J]. Ann Intensive Care,2019,9(1):50.
[8] Nagareddy P,Smyth SS. Inflammation and thrombosis in cardiovascular disease[J]. Curr Opin Hematol,2013,20(5):457-463.
[9] Petrof BJ. Diaphragm weakness in the critically ill basic mechanisms reveal therapeutic opportunities[J]. Chest,2018,154(6):1395-1403.
[10] Dres M,Dubé BP,Mayaux J,et al. Coexistence and impact of limb muscle and diaphragm weakness at time of liberation from mechanical ventilation in medical intensive care unit patients[J]. Am J Respir Crit Care Med,2017,195(1):57-66.
[11] Zambon M,Greco M,Bocchino S,et al. Assessment of diaphragmatic dysfunction in the critically ill patient with ultrasound:a systematic review[J]. Intensive Care Med,2017,43(1):29-38.
[12] Lee JB,Tse C,Keowm T,et al. Evaluation of a point of care ultrasound curriculum for Indonesian physicians taught by first-year medical students[J]. World J Emerg Med,2017,8(4):281-286.
[13] Rooney KP,Lahham S,Lahham S,et al. Pre-hospital assessment with ultrasound in emergencies:implementation in the field[J]. World J Emerg Med,2016,7(2):117-123.
[14] Kim WY,Lim CM. Ventilator-induced diaphragmatic dysfunction:diagnosis and role of pharmacological agents[J]. Respir Care,2017,62(11):1485-1491.
[15] 郝光伟,俞颖,马国光,等. 超声评估A型主动脉夹层术后膈肌功能不全:发生率、危险因素及对预后的影响[J]. 中华急诊医学杂志,2018,27(8):887-892.
[16] Maes K,Stamiris A,Thomas D,et al. Effects of controlled mechanical ventilation on sepsis-induced diaphragm dysfunction in rats[J]. Crit Care Med,2014,42(12):e772-e782.

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备注/Memo

备注/Memo:

通信作者: 章淬,E-mail: 18951670283@163.com

收稿日期:2022-01-13基金项目:南京市科技发展计划项目(201611002)
更新日期/Last Update: 2022-08-22