先天性膈疝患儿术后肺功能评估及影响因素分析

doi:10.3969/j.issn.1674-8115.2021.09.006

摘要/Abstract

摘要：

目的·分析先天性膈疝（congenital diaphragmatic hernia，CDH）患儿术后肺功能状态，探讨影响肺功能恢复的相关因素。方法·回顾性分析2016年11月—2020年11月在上海交通大学医学院附属新华医院儿外科门诊进行随访并行儿童肺功能检查的CDH患儿。对患儿肺功能检查结果按通气功能障碍类型分为限制组、阻塞组、混合组和正常组，分析各组在患儿是否为产前诊断、诊断孕周、观察/期望肺头比（observed/expected lung-to-head ratio，O/E LHR）、出生体质量、出生后1 min Apgar评分、疝侧、肝脏是否疝入、术中是否应用补片、呼吸机使用时间、住院天数、检查月龄和术后随访时间方面的差异。分析诊断孕周是否小于25周、肝脏是否疝入、术中是否应用补片对每千克体质量潮气量（tidal volume per kg of body weight，TV/kg）、50%剩余潮气量时的潮气呼气流速（tidal expiratory flow 50% remaining tidal volume，TEF50%）等首次肺功能检查指标的影响。分析CDH术后随访患儿首次和末次肺功能检查指标的差异。结果·共有42例患儿纳入分析，16例患儿行1次检查，26例行2次及以上检查，共行96次肺功能检查。限制组（6次）、阻塞组（68次）、混合组（9次）、正常组（13次）患儿在检查时月龄和术后随访时间的差异有统计学意义（P=0.004，P=0.002）。<25周诊断组患儿的TV/kg和TEF50%较≥25周诊断组低（P=0.022，P=0.043），肝脏疝入组患儿的TEF75%和TEF50%较非肝脏疝入组低（均P=0.040），使用补片组患儿的TEF50%和TEF25%较未使用补片组低（P=0.034，P=0.020）。O/E LHR越高，达峰时间比、达峰容积比越高（r=0.393，P=0.005；r=0.324，P=0.023）；呼吸机使用时间越少，达峰时间比、达峰容积比越高（r=-0.377，P=0.000；r=-0.314，P=0.002）。术后1个月内，阻塞性通气功能障碍6次（46.2%）；术后3个月后，阻塞性通气功能障碍为49次（77.8%）。在接受多次肺功能检查的患儿中，随着随访时间延长，其末次检查的TV/kg、TEF75%、TEF50%、TEF25%较首次肺功能检查时有所增加（P=0.001，P=0.003，P=0.001，P=0.000），呼吸频率减少（P=0.010）。结论·孕25周前诊断、肝脏疝入及术中应用补片的CDH患儿，术后潮气呼吸肺功能更差。术后早、晚期通气功能障碍均主要表现为阻塞性。随着随访时间的推移，CDH患儿肺功能有所改善。

关键词: 先天性膈疝, 肺功能, 随访, 预测因素

Abstract:

Objective·To analyze the postoperative pulmonary function of children with congenital diaphragmatic hernia (CDH) and explore the related factors affecting the recovery of pulmonary function.

Methods·The medical data of children with CDH who were treated in the Department of Pediatric Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, and underwent infant pulmonary function test (IPFT) from November 2016 to November 2020 were retrospectively reviewed. According to the type of ventilatory dysfunction in the examination, the children were divided into restrictive group, obstructive group, mixed group and healthy group. The differences in prenatal diagnosis, diagnostic gestational week, observed/expected lung-to-head ratio (O/E LHR), birth weight, 1 min Apgar score, hernia side, liver-up, use of patch during operation, duration of mechanical ventilation, length of hospital stay, month age at the time of IPFT and postoperative follow-up time in each group were analyzed. The pulmonary function results of the first-time test were analyzed in the diagnosis of whether the gestational age was less than 25 weeks, whether there was a liver-up and whether the patch was used during the operation. The difference between the results of the first and last test was analyzed.

Results·Fourty-two children were included in the analysis. A total of 96 tests were conducted in patients. Sixteen cases underwent IPFT once, and 26 cases had 2 or more tests. There were significant differences in month age at the time of IPFT and postoperative follow-up time among the restrictive (n=6), obstructive (n=68), mixed (n=9) and healthy (n=13) groups (P=0.004, P=0.002). Overall, the tidal volume per kg of body weight (TV/kg), and tidal expiratory flow 50% remaining tidal volume (TEF50%) in children with diagnosis of gestational age less than 25 weeks were lower (P=0.022, P=0.043), TEF75% and TEF50% in children with liver-up were lower (both P=0.040), and TEF50% and TEF25% in children with use of patch during operation were lower (P=0.034, P=0.020). The higher the O/E LHR, the higher the ratio of time to peak tidal expiratory flow to total expiratory time (TPEF/TE) and the ratio of volume at peak tidal expiratory flow to expiratory tidal volume (VPEF/VE) (r=0.393, P=0.005; r=0.324, P=0.023). The less the duration of mechanical ventilation, the higher the TPEF/TE and VPEF/VE (r=-0.377, P=0.000; r=-0.314, P=0.002). Within 1 month after operation, obstructive ventilatory dysfunction occurred 6 times (46.2%), and obstructive ventilatory dysfunction was found 49 times (77.8%) 3 months after operation. In patients who received IPFT twice or more, with the increase of follow-up time, TV/kg, TEF75%, TEF50% and TEF25% in the last IPFT were higher than those in the first test (P=0.001, P=0.003, P=0.001, P=0.000), and the respiratory rate decreased (P=0.010).

Conclusion·The tidal respiratory function of CDH children diagnosed before the first 25 weeks of pregnancy, with liver-up and intraoperative patch use is even worse. The main manifestation of early and late postoperative ventilatory dysfunction is obstruction. With the passage of time of postoperative follow-up, the pulmonary function of children with CDH is improved.

Key words: congenital diaphragmatic hernia (CDH), pulmonary function, follow-up, predictive factor

中图分类号:

R726

王雪瑶, 潘伟华, 王伟鹏, 刘全华, 谢伟, 王磊, 王俊. 先天性膈疝患儿术后肺功能评估及影响因素分析[J]. 上海交通大学学报(医学版), 2021, 41(9): 1169-1174.

Xue-yao WANG, Wei-hua PAN, Wei-peng WANG, Quan-hua LIU, Wei XIE, Lei WANG, Jun WANG. Evaluation of postoperative pulmonary function in children with congenital diaphragmatic hernia and analysis of influencing factors[J]. JOURNAL OF SHANGHAI JIAOTONG UNIVERSITY (MEDICAL SCIENCE), 2021, 41(9): 1169-1174.

图/表 4

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Item	Restrictive group （n=6）	Obstructive group （n=68）	Mixed group （n=9）	Healthy group （n=13）	P value
Prenatal diagnosis/n（%）	6 （100.0）	60 （88.2）	9 （100.0）	12 （92.3）	0.913
Gestational week at diagnosis/week	23.7 （22.8， 1.1）	24.1（23.0， 35.8）	23.0 （22.0， 24.4）	24.3 （23.0， 28.0）	0.327
O/E LHR/%	59.9 （47.8， 61.8）	59.9 （46.9， 60.1）	47.2 （33.5， 78.8）	60.1 （46.1， 63.5）	0.684
Birth weight/g	3 480.0 （3 250.0， 4 000.0）	3 230.0 （2 787.5， 3 300.0）	2 700.0 （2 600.0， 3 350.0）	3 016.0 （2 900.0， 3 300.0）	0.098
1 min Apgar score/score	8.7±0.8	8.8±1.1	8.0±1.3	9.1±1.0	0.936
Hernia side （left）/n（%）	4 （66.7）	58 （85.3）	7 （77.8）	11 （84.6）	0.543
Liver-up^①/n（%）	2 （50.0）	10 （28.6）	2 （50.0）	2 （50.0）	0.657
Patch use/n（%）	1 （16.7）	12 （17.6）	2 （22.2）	1 （7.7）	0.812
Mechanical ventilation time/d	6.5±7.6	10.0±7.6	13.2±11.0	5.6±4.1	0.079
Hospital length of stay/d	21.5 （16.8， 31.3）	29.0 （20.0， 31.0）	26.0 （20.5， 46.0）	21.0 （18.0， 31.0）	0.531
Month age at the time of test/month	1.0 （1.0， 3.0）	5.0 （3.0， 9.0）	6.0 （1.5， 9.0）	3.0 （2.0， 4.0）	0.004
Postoperative follow-up age/month	1.0 （1.0， 2.3）	5.5 （3.0， 9.3）	6.0 （1.5， 9.0）	3.0 （2.0， 3.0）	0.002

Item	Restrictive group （n=6）	Obstructive group （n=68）	Mixed group （n=9）	Healthy group （n=13）	P value
Prenatal diagnosis/n（%）	6 （100.0）	60 （88.2）	9 （100.0）	12 （92.3）	0.913
Gestational week at diagnosis/week	23.7 （22.8， 1.1）	24.1（23.0， 35.8）	23.0 （22.0， 24.4）	24.3 （23.0， 28.0）	0.327
O/E LHR/%	59.9 （47.8， 61.8）	59.9 （46.9， 60.1）	47.2 （33.5， 78.8）	60.1 （46.1， 63.5）	0.684
Birth weight/g	3 480.0 （3 250.0， 4 000.0）	3 230.0 （2 787.5， 3 300.0）	2 700.0 （2 600.0， 3 350.0）	3 016.0 （2 900.0， 3 300.0）	0.098
1 min Apgar score/score	8.7±0.8	8.8±1.1	8.0±1.3	9.1±1.0	0.936
Hernia side （left）/n（%）	4 （66.7）	58 （85.3）	7 （77.8）	11 （84.6）	0.543
Liver-up^①/n（%）	2 （50.0）	10 （28.6）	2 （50.0）	2 （50.0）	0.657
Patch use/n（%）	1 （16.7）	12 （17.6）	2 （22.2）	1 （7.7）	0.812
Mechanical ventilation time/d	6.5±7.6	10.0±7.6	13.2±11.0	5.6±4.1	0.079
Hospital length of stay/d	21.5 （16.8， 31.3）	29.0 （20.0， 31.0）	26.0 （20.5， 46.0）	21.0 （18.0， 31.0）	0.531
Month age at the time of test/month	1.0 （1.0， 3.0）	5.0 （3.0， 9.0）	6.0 （1.5， 9.0）	3.0 （2.0， 4.0）	0.004
Postoperative follow-up age/month	1.0 （1.0， 2.3）	5.5 （3.0， 9.3）	6.0 （1.5， 9.0）	3.0 （2.0， 3.0）	0.002

Item	Gestational week at diagnosis			Liver-up			Patch use
Item	<25 weeks	≥25 weeks	P value	Yes	No	P value	Yes	No	P value
TV/kg/（mL·kg^-1）	6.2±1.7	7.7±2.0	0.022	6.2±2.6	7.7±1.7	0.151	6.3±1.7	6.9±2.0	0.486
RR/（times·min^-1）	46.0±10.2	38.6±13.5	0.075	46.0±11.3	38.6±13.7	0.958	44.2±10.2	42.5±13.5	0.768
I/E ratio	0.8±0.1	0.8±0.2	0.588	0.8±0.2	0.8±0.2	0.966	0.7±0.1	0.8±0.2	0.226
TPEF/TE/%	24.5±10.7	25.0±10.8	0.907	24.5±10.6	25.0±8.0	0.561	19.9±10.7	25.5±10.8	0.265
VPEF/VE/%	26.3±9.8	26.5±8.3	0.956	26.3±9.0	26.5±6.5	0.537	22.7±9.8	26.9±8.3	0.319
TEF75%/（mL·s^-1）	68.8±20.7	88.3±36.3	0.053	68.8±39.5	88.3±32.5	0.040	58.0±20.7	80.7±36.3	0.090
TEF50%/（mL·s^-1）	60.6±19.8	78.1±29.3	0.043	60.6±31.2	78.1±25.4	0.040	47.6±19.8	71.9±29.3	0.034
TEF25%/（mL·s^-1）	44.9±16.0	57.0±22.1	0.069	44.9±26.8	57.0±17.0	0.078	33.0±16.0	53.6±22.1	0.020

Item	Gestational week at diagnosis			Liver-up			Patch use
Item	<25 weeks	≥25 weeks	P value	Yes	No	P value	Yes	No	P value
TV/kg/（mL·kg^-1）	6.2±1.7	7.7±2.0	0.022	6.2±2.6	7.7±1.7	0.151	6.3±1.7	6.9±2.0	0.486
RR/（times·min^-1）	46.0±10.2	38.6±13.5	0.075	46.0±11.3	38.6±13.7	0.958	44.2±10.2	42.5±13.5	0.768
I/E ratio	0.8±0.1	0.8±0.2	0.588	0.8±0.2	0.8±0.2	0.966	0.7±0.1	0.8±0.2	0.226
TPEF/TE/%	24.5±10.7	25.0±10.8	0.907	24.5±10.6	25.0±8.0	0.561	19.9±10.7	25.5±10.8	0.265
VPEF/VE/%	26.3±9.8	26.5±8.3	0.956	26.3±9.0	26.5±6.5	0.537	22.7±9.8	26.9±8.3	0.319
TEF75%/（mL·s^-1）	68.8±20.7	88.3±36.3	0.053	68.8±39.5	88.3±32.5	0.040	58.0±20.7	80.7±36.3	0.090
TEF50%/（mL·s^-1）	60.6±19.8	78.1±29.3	0.043	60.6±31.2	78.1±25.4	0.040	47.6±19.8	71.9±29.3	0.034
TEF25%/（mL·s^-1）	44.9±16.0	57.0±22.1	0.069	44.9±26.8	57.0±17.0	0.078	33.0±16.0	53.6±22.1	0.020

Item	TPEF/TE		VPEF/VE
Item	r value	P value	r value	P value
O/E LHR	0.393	0.005	0.324	0.023
Gestational week at diagnosis	-0.047	0.675	-0.043	0.704
Mechanical ventilation time	-0.377	0.000	-0.314	0.002