Perioperative Pulmonary Atelectasis: Part II. Clinical Implications.
Perioperative Pulmonary Atelectasis: Part II. Clinical Implications.
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DOI：
10.1097/aln.0000000000004009
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发表时间：
2022-01-01
期刊：
影响因子：
8.8
通讯作者：
Melo, Marcos F. Vidal
中科院分区：
文献类型：
--
作者：
Lagier, David;Zeng, Congli;Fernandez-Bustamante, Ana;Melo, Marcos F. Vidal
肺不张的发展是常见的手术病人。肺不张在手术中和手术后可引起不同程度的气体交换和呼吸力学损伤。在最严重的情况下，肺萎陷可能导致术后呼吸功能不全、肺炎和更差的总体临床结果。具体的风险评估对于临床医生选择最佳麻醉技术、准备适当的监测、调整围手术期计划和确保患者安全至关重要。床边诊断和管理得益于最近影像学的进步，如肺超声和电阻抗断层扫描，以及食管测压仪等监测。治疗管理包括一系列旨在促进肺再募集的干预措施。在全身麻醉期间，这些策略在改善术中氧合和呼吸顺应性方面一直被证明是有效的。然而，这些相同的术中策略可能无法影响其他术后肺预后。特别注意术后时期可能是影响肺扩张结果的关键。无创正压通气支持等干预措施可能对肺不张高危患者（如肥胖）或临床表现与肺萎陷一致的患者（如腹部和心胸外科手术后低氧血症）有益。术前干预可能为减少围手术期肺塌陷和预防肺部并发症提供新的机会。了解肺不张的病理生理机制及其对健康和患病肺的影响应该为当前的实践提供基础，并有助于分层和匹配所选干预措施的强度。本文综述了肺不张临床危险因素的最新证据和先进的诊断方法。基于肺影像学研究和最近的临床试验，为临床医生提供围手术期治疗管理的新视角。
The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan and ensure patient’s safety. Bedside diagnosis and management have benefited from recent imaging advancements, such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management include a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet, these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as non-invasive positive pressure ventilatory support are likely beneficial in patients at high-risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardio-thoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiological mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions. Up-to-date evidence on clinical risk factors, and advanced diagnostic approaches of pulmonary atelectasis are reviewed. Novel perspectives on perioperative therapeutic management based on lung imaging studies and recent clinical trials are provided to clinicians.