不同膈肌超声功能指标在腹部手术后肺部并发症中的预测价值

doi:10.6040/j.issn.1671-7554.0.2024.0260

摘要/Abstract

摘要： 目的比较不同膈肌超声功能指标:平静呼吸膈肌移动度(diaphragmatic excursion during quiet breathing, DE-QB)、深呼吸膈肌移动度(diaphragmatic excursion during deep breathing, DE-DB)、膈肌增厚分数(thickening fraction of diaphragm, TFdi)在腹部手术术后肺部并发症(postoperative pulmonary complications, PPCs)中的预测价值。方法选取全麻下行腹腔镜腹部手术患者154 例,在术前和术后24 h分别行床旁超声测量患者DE-QB、DE-DB和TFdi。记录术后7 d肺部并发症情况,以是否发生PPCs,将患者分为PPCs组(n=48)和n-PPCs组(n=106),比较两组患者膈肌功能指标间的差异。选取差异显著的膈肌功能指标绘制受试者工作特征(receiver operating characteristic, ROC)曲线,以3种功能指标ROC曲线的最佳界值将患者分为PPCs高风险组和PPCs低风险组。分析3种膈肌超声功能指标对腹部手术PPCs预测价值,通过Lasso-Logistic回归分析建立PPCs的预测模型,并与单一膈肌功能指标进行对比。结果 PPCs组和n-PPCs组术前DE-QB、DE-DB和TFdi差异无统计学意义(P>0.05),PPCs组术后DE-QB、DE-DB和TFdi均低于n-PPCs组,差异有统计学意义( P<0.001),术后DE-QB,DE-DB,TFdi的ROC曲线的曲线下面积(area under the curve, AUC)分别为0.780、0.779、0.713,三者间无明显差异。以术后DE-QB区分患者时(最佳界值为0.93 cm),PPCs高风险组与PPCs低风险组肺部并发症发生率差异有统计学意义(14.1% vs. 61.8%,P<0.001);以术后DE-DB区分患者时(最佳界值为2.41 cm),PPCs高风险组与PPCs低风险组肺部并发症发生率差异有统计学意义(13.3% vs. 56.3%,P<0.001);以术后TFdi区分患者时(最佳界值为0.23),PPCs高风险组与PPCs低风险组肺部并发症发生率差异有统计学意义(16.5% vs. 52.4%,P<0.001)。通过Lasso-Logistic回归分析,最终纳入预测模型的危险因素包括年龄、吸烟史、手术时间、术后DE-QB和术后DE-DB,Lasso-Logistic回归模型(AUC=0.851)优于任一单一膈肌功能指标。结论术后24 h DE-QB、DE-DB和TFdi单独使用时均能在一定程度上预测PPCs的发生率,但通过测量膈肌移动度(diaphragmatic excursion, DE)对PPCs的预测价值优于TFdi。通过Lasso-Logistic回归建立的预测模型相较于单一膈肌功能指标可以更好地预测PPCs的发生率。

关键词: 膈肌移动度, 膈肌增厚分数, 腹部手术, 超声, 肺部并发症

Abstract: Objective To compare different diaphragmatic ultrasound functional indices, diaphragmatic excursion during quiet breathing(DE-QB), diaphragmatic excursion during deep breathing(DE-DB), thickening fraction of diaphragm(TFdi), in predicting postoperative pulmonary complications(PPCs)after abdominal surgery. Methods A total of 154 patients scheduled for elective laparoscopic abdominal surgery under general anesthesia were selected. DE-QB, DE-DB, and TFdi were measured by bedside ultrasound before and 24 hours after surgery. Postoperative pulmonary complications were recorded for 7 days. Patients were divided into two groups according to the occurrence of pulmonary complications: the pulmonary complications group(PPCs group, n=48)and the non-pulmonary complications group(n-PPCs group, n=106). The differences in diaphragm function indices between the two groups were compared, and those with significant differences were selected to plot ROC curves. The ROC curves were compared to assess the predictive value of three ultrasound diaphragmatic functional indices for postoperative pulmonary complications after abdominal surgery. A predictive model for postoperative pulmonary complications was created using Lasso Logistic regression analysis and compared with individual diaphragmatic functional indices. Results The differences in preoperative DE-QB, DE-DB, and TFdi between the two groups were not statistically significant(P>0.05). However, the postoperative DE-QB, DE-DB, and TFdi in the PPCs group were lower than those in the n-PPCs group, with statistically significant differences(P<0.001). The areas under the ROC curve(AUC)for postoperative DE-QB, DE-DB, and TFdi were 0.780, 0.779, and 0.713, respectively, with no significant differences. Patients were divided into high-risk PPCs and low-risk PPCs groups according to the optimal cut-off value of the ROC curves of the three functional indices. When patients were differentiated by postoperative DE-QB(optimal cut-off value of 0.93 cm), the incidence of pulmonary complications differed between the high-risk and the low-risk groups(14.1% vs. 61.8%, P<0.001); when patients were differentiated by postoperative DE-DB(optimal cut-off value of 2.41 cm), there was a difference in the incidence of pulmonary complications between the high-risk and the low-risk groups(13.3% vs. 56.3%, P<0.001); when patients were differentiated by postoperative TFdi(optimal cut-off value of 0.23), there was a difference in the incidence of pulmonary complications between the high-risk and the low-risk groups(16.5% vs. 52.4%, P<0.001). By Lasso Logistic regression analysis, the final risk factors included in the prediction model were age, smoking history, duration of surgery, DE-QB(postoperative), and DE-DB(postoperative), and the Lasso Logistic regression model(AUC=0.851)outperformed any single index of diaphragm function. Conclusion The DE-QB, DE-DB and TFdi measured at 24h post-operatively alone can predict the occurrence of post-operative pulmonary complications(PPCs)to some extent when used individually, however the measurement of diaphragmatic excursion(DE)provided better predictive value for PPCs than TFdi. The predictive model established by Lasso Logistic regression can better predict the incidence of PPCs than any single diaphragm function index.

Key words: Diaphragm excursion, Fraction of diaphragm thickening, Abdominal surgery, Ultrasound, Pulmonary complications

中图分类号:

R572

李红梅,蔡敏,周立,姚欣雨,刘力. 不同膈肌超声功能指标在腹部手术后肺部并发症中的预测价值[J]. 山东大学学报 (医学版), 2024, 62(10): 115-124.

LI Hongmei, CAI Min, ZHOU Li, YAO Xinyu, LIU Li. Comparison of different diaphragmatic ultrasound functional indices in predicting pulmonary complications after abdominal surgery[J]. Journal of Shandong University (Health Sciences), 2024, 62(10): 115-124.

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