1. オペ室から
換気量制限すべき??
JA広島総合病院 救急・集中治療科
櫻谷 正明
JA Hiroshima General Hospital
Journal Club
113年8月20日火曜日

2. 手術中の換気量
古くから, 低酸素や無気肺の防止のために, 全身麻酔下
の患者管理では, 10-15ml/kg（IBW）の高容量の換気
が推奨されてきた.
Bendixen HH, Hedley-Whyte J, Laver MB. Impaired oxygenation in surgical pa- tients during general
anesthesia with con- trolled ventilation: a concept of atelecta- sis. N Engl J Med 1963;269:991-6.
しかし, 高容量にすると肺胞の過進展が生じ, VALIが起
こり, 炎症性メディエーターが産生され, 全身に影響を与
えるため, 多臓器不全に伸展する可能性がある.
Association between use of lung- protective ventilation with lower tidal vol- umes and clinical outcomes
among pa- tients without acute respiratory distress syndrome: a meta-analysis. JAMA 2012; 308:1651-9.
213年8月20日火曜日

3. 手術中の肺保護戦略
換気量制限やPEEP, RMといった肺保護戦略はARDS患者の死亡率を
低下させ, 多くの重症患者に対してのbest practiceとされている.
Putensen C, Theuerkauf N, Zinserling J, Wrigge H, Pelosi P. Meta-analysis: ventilation strategies and outcomes of the acute
respiratory distress syndrome and acute lung injury. Ann Intern Med 2009; 151:566-76.
手術時からの肺保護戦略を目的とした人工呼吸器設定が有益かどうか
についてはまだ疑問が残り, 日々の麻酔管理ではほとんどがNo PEEP,
High tidal volumesであり, 肺保護戦略をされているのは20%以下
に過ぎない.
Wrigge H, Uhlig U, Baumgarten G, et al. Mechanical ventilation strategies and inflammatory responses to cardiac sur- gery: a
prospective randomized clinical trial. Intensive Care Med 2005;31:1379-87.
Jaber S, Coisel Y, Chanques G, et al. A multicentre observational study of intra- operative ventilatory management during general
anaesthesia: tidal volumes and re- lation to body weight. Anaesthesia 2012; 67:999-1008.
313年8月20日火曜日

4. 腹部手術での低容量換気.
Emmanuel Futier, M.D., Jean-Michel Constantin, M.D., Ph.D., Catherine Paugam-Burtz, M.D., Ph.D., et al.
A Trial of Intraoperative Low-Tidal-Volume Ventilation in Abdominal Surgery. N Engl J Med 2013; 369:428-437.
413年8月20日火曜日

5. method
RCT, double-blind, 大学病院7施設, フランス, 2011年1月31日から2012年8月10日まで.
対象:
40歳以上, 少なくとも2時間以上と思われる腹部の予定手術, 周術期の肺合併症リスク >2.
除外:
手術に先立ち2週間以内に, 人工呼吸を受けている, 呼吸不全, 敗血症の既往がある.
BMI 35kg/m2, 進行性の神経筋疾患.
Intervention: 両群ともにVCVを用い, プラトー圧 30cmH2O, SpO2 92%の時は一時的に
FiO2 100%にしたり, nonprotectiveでもPEEPをかけたり, RMを行うことを許可した.
nonprotective: Vt 10-12ml/kg IBW, no PEEP, no RM.
protective: Vt 6-8ml/kg IBW, PEEP 6-8cmH2O, RM 挿管後より30分毎（30cmH2O, 30秒）.
Primary outcome: 肺および肺外の合併症.
major pulmonary complication: 肺炎, IPPVやNPPVが必要.
major extrapulmonary complication: sepsis, severe sepsis, septic shock, 死亡.
513年8月20日火曜日

6. preoperative risk index for postoperative
pulmonary complications
Risk Factor Point
手術の種類
AAA repair 15
上腹部手術 10
年齢
80歳 17
70-79歳 13
60-69歳 9
50-59歳 4
機能
完全自立 10
部分的に自立 6
半年で10%を超える体重減少 7
COPDの既往 5
Risk Factor Point
全身麻酔 4
意識障害 4
脳血管疾患の既往 4
BUN
< 8mg/dl 4
22-30mg/dl 2
30mg/dl 3
4単位以上の輸血 3
緊急手術 3
慢性的なステロイド使用 3
1年以内の喫煙 3
過去2週間以内に2回以上の喫煙 2
Risk
Class
points
1 15
2 16-25
3 26-40
4 41-55
5 >55
613年8月20日火曜日

7. 合併症を減少.
7日以内の合併症
Nonprotective 27.5%
Protective 10.5%
• p <0.001
30日以内の合併症
Nonprotective 29.0%
Protective 12.5%
• p <0.001
The new engl and jour nal o f medicine
ment maneuvers, in which hemodynamic effects
are potentially influenced by the applied level of
alveolar pressure,36 should be used with caution
in patients with hemodynamic instability.
There are several limitations to our study. The
trial design did not include standardization of
the administration of fluids. However, this limi-
tation is unlikely to have affected our results,
since the volume of fluids administered was
similar in the two groups. The definition of
nonprotective ventilation was arbitrary but is
supported in the literature.19,20 The trial protocol
did not include standardization of requirements
for noninvasive ventilation; however, it was rec-
ommended that the study centers follow clinical-
practice guidelines,37,38 and postoperative care
was conducted by health care workers who were
unaware of the study assignments. The utiliza-
tion of noninvasive ventilation in our trial is
close to that reported in earlier studies.37 We
therefore consider it unlikely that any imbalance
in interventions affected our results.
In conclusion, our study provides evidence that
a multifaceted strategy of prophylactic lung-pro-
ProbabilityofEvent
0.50
0.30
0.40
0.20
0.10
0.00
1 3 7 3015
Days since Randomization
No. at Risk
Nonprotective
ventilation
Lung-protective
ventilation
200
200
182
192
163
184
145
179
142
176
142
175
Lung-protective ventilation
Nonprotective ventilation
Figure 2. Kaplan–Meier Estimates of the Probability of the Composite
Primary Outcome.
Data for the Kaplan–Meier estimates of the probability of the composite
primary outcome of major pulmonary or extrapulmonary complications
were censored at 30 days after surgery. Major pulmonary complications
included pneumonia or the need for invasive or noninvasive ventilation for
acute respiratory failure. Major extrapulmonary complications were sepsis,
手術中の肺保護戦略が, 合併症を減らした.
713年8月20日火曜日

8. 無気肺, 肺炎, sepsis, 在院日数など減少.
Intraoperative Low-Tidal-Volume Ventilation
Table 3. Results of Unadjusted and Adjusted Outcome Analyses.*
Variable
Nonprotective
Ventilation
(N=200)
Lung-Protective
Ventilation
(N=200)
Unadjusted
Relative Risk or
Between-Group
Difference
(95% CI) P Value†
Adjusted
Relative Risk or
Between-Group
Difference
(95% CI)‡ P Value
Primary composite outcome — no. (%)
Within 7 days§ 55 (27.5) 21 (10.5) 0.38 (0.24–0.61) <0.001 0.40 (0.24–0.68) 0.001
Within 30 days 58 (29.0) 25 (12.5) 0.43 (0.28–0.66) <0.001 0.45 (0.28–0.73) <0.001
Secondary outcomes — no. (%)
Pulmonary complication within 7 days¶
Grade 1 or 2 30 (15.0) 25 (12.5) 0.69 (0.42–1.13) 0.14 0.67 (0.39–1.16) 0.16
Grade ≥3 42 (21.0) 10 (5.0) 0.24 (0.12–0.46) <0.001 0.23 (0.11–0.49) <0.001
Atelectasis within 7 days 34 (17.0) 13 (6.5) 0.38 (0.21–0.70) 0.001 0.37 (0.19–0.73) 0.004
Pneumonia within 7 days 16 (8.0) 3 (1.5) 0.19 (0.05–0.63) 0.01 0.19 (0.05–0.66) 0.009
Acute lung injury or ARDS within 7 days 6 (3.0) 1 (0.5) 0.17 (0.02–1.37) 0.12 0.21 (0.02–1.71) 0.14
Need for ventilation within 7 days
Invasive 7 (3.5) 2 (1.0) 0.29 (0.06–1.36) 0.51 0.40 (0.08–1.97) 0.26
Noninvasive 29 (14.5) 9 (4.5) 0.31 (0.15–0.64) 0.006 0.29 (0.13–0.65) 0.002
Extrapulmonary complication within 7 days
SIRS 100 (50.0) 86 (43.0) 0.86 (0.70–1.06) 0.16 0.87 (0.65–1.17) 0.37
Sepsis 29 (14.5) 13 (6.5) 0.45 (0.24–0.84) 0.04 0.48 (0.25–0.93) 0.03
Severe sepsis or septic shock 9 (4.5) 8 (4.0) 0.89 (0.35–2.26) 0.80 1.48 (0.51–4.32) 0.47
Death within 30 days 7 (3.5) 6 (3.0) 0.86 (0.29–2.51) 0.80 1.13 (0.36–3.61) 0.83
Duration of stay in hospital and ICU — days
Hospital 0.02 0.006
Median 13 11 −2.25 (−4.04 to −0.47) −2.45 (−4.17 to −0.72)
Interquartile range 8–20 8–15
ICU 0.58 0.69
Median 7 6 −1.48 (−6.87 to 3.91) −1.21 (−4.98 to 7.40)
Interquartile range 4–9 4–8
Intraoperative Low-Tidal-Volume Ventilation
Table 3. Results of Unadjusted and Adjusted Outcome Analyses.*
Variable
Nonprotective
Ventilation
(N=200)
Lung-Protective
Ventilation
(N=200)
Unadjusted
Relative Risk or
Between-Group
Difference
(95% CI) P Value†
Adjusted
Relative Risk or
Between-Group
Difference
(95% CI)‡ P Value
Primary composite outcome — no. (%)
Within 7 days§ 55 (27.5) 21 (10.5) 0.38 (0.24–0.61) <0.001 0.40 (0.24–0.68) 0.001
Within 30 days 58 (29.0) 25 (12.5) 0.43 (0.28–0.66) <0.001 0.45 (0.28–0.73) <0.001
Secondary outcomes — no. (%)
Pulmonary complication within 7 days¶
Grade 1 or 2 30 (15.0) 25 (12.5) 0.69 (0.42–1.13) 0.14 0.67 (0.39–1.16) 0.16
Grade ≥3 42 (21.0) 10 (5.0) 0.24 (0.12–0.46) <0.001 0.23 (0.11–0.49) <0.001
Atelectasis within 7 days 34 (17.0) 13 (6.5) 0.38 (0.21–0.70) 0.001 0.37 (0.19–0.73) 0.004
Pneumonia within 7 days 16 (8.0) 3 (1.5) 0.19 (0.05–0.63) 0.01 0.19 (0.05–0.66) 0.009
Acute lung injury or ARDS within 7 days 6 (3.0) 1 (0.5) 0.17 (0.02–1.37) 0.12 0.21 (0.02–1.71) 0.14
Need for ventilation within 7 days
Invasive 7 (3.5) 2 (1.0) 0.29 (0.06–1.36) 0.51 0.40 (0.08–1.97) 0.26
Noninvasive 29 (14.5) 9 (4.5) 0.31 (0.15–0.64) 0.006 0.29 (0.13–0.65) 0.002
Extrapulmonary complication within 7 days
SIRS 100 (50.0) 86 (43.0) 0.86 (0.70–1.06) 0.16 0.87 (0.65–1.17) 0.37
Sepsis 29 (14.5) 13 (6.5) 0.45 (0.24–0.84) 0.04 0.48 (0.25–0.93) 0.03
Severe sepsis or septic shock 9 (4.5) 8 (4.0) 0.89 (0.35–2.26) 0.80 1.48 (0.51–4.32) 0.47
Death within 30 days 7 (3.5) 6 (3.0) 0.86 (0.29–2.51) 0.80 1.13 (0.36–3.61) 0.83
Duration of stay in hospital and ICU — days
Hospital 0.02 0.006
Median 13 11 −2.25 (−4.04 to −0.47) −2.45 (−4.17 to −0.72)
Interquartile range 8–20 8–15
ICU滞在日数や死亡率には差がなかった.
813年8月20日火曜日

9. LTV + PEEP + RM
対象が, ある程度の高リスク患者.
低リスク患者では, これほどの差はないかもしれない.
低容量換気のほか, PEEPやRMも必要.
換気量制限が良いのか, No PEEPがいけないのか??
低すぎるPEEPは, 無気肺や肺合併症につながる.
RMは循環動態に影響を与える.
913年8月20日火曜日

10. この研究の強みと弱み
Strengths
ハイリスク患者に関連の大きいアウトカムであること.
バイアスを最小限にしている（RCT, double-blind, ITT解析,
complete follow-up）.
Limitations
輸液投与量を決めていない（結果的には, 両群間で差はなかった）.
対照群の非肺保護戦略の定義が普遍的なものではなく, 独自で決めた.
NPPV開始基準を決めていない（ガイドラインに基づいて診療を行っ
ている）.
1013年8月20日火曜日

11. 結論
腹部手術中に肺保護戦略を行うことで, 術後の
合併症を減らし, 入院日数を短縮した.
1113年8月20日火曜日