6分钟步行试验在肺叶切除术患者术前评估中的应用

doi:10.3969/j.issn.1006-9771.2022.02.016

摘要/Abstract

摘要：

目的分析术前6分钟步行试验(6MWT)在肺叶切除术前评估应用的可行性及其对术后结局的预测价值。方法回顾性分析2017年5月至2019年5月在本院肺二科住院的580例患者,筛查出符合条件的274例,所有患者均为首次手术且手术方式均为肺叶切除术。通过术前6MWT结果将患者分为两组,6分钟步行距离(6MWD)的临界值通过接受者操作特征曲线(ROC)的曲线下最大面积(AUC)获得,分析两组术后恢复及心肺并发症的发生情况。结果与6MWD > 449 m的患者比较,6 MWD ≤ 449 m的患者年龄显著增加(P < 0.001),第一秒用力呼气量(FEV₁)较小(P < 0.05),其他如手术切除部位、病理分期、性别等无显著性差异(P > 0.05);术后心肺并发症的发生率明显增加(OR =2.672, 95%CI 1.488~4.798, P = 0.002),术后拔管时间和住院天数增加(P < 0.05)。6MWD ≤ 449 m是术后心肺并发症的独立危险因素(OR = 2.395, 95%CI 1.299~4.415, P = 0.005)。结论 6MWT作为一种简易的运动功能测试,可常规应用于肺叶切除术患者术前的生理功能评估。当6MWD ≤ 449 m时,患者术后发生心肺并发症的风险较高。

关键词: 6分钟步行测试, 肺叶切除术, 术前评估

Abstract:

Objective To analyze the feasibility of six-minute walk test (6MWT) before pulmonary lobectomy and prediction for postoperative outcome. Methods A total of 580 patients who were hospitalized in the department of lung surgery from May, 2017 to May, 2019 were reviewed, and 274 eligible patients were selected, who underwent first surgery and the surgical method was pulmonary lobectomy. They were divided into two groups based on the results of 6MWT before operation. The cut-off value of six-minute walk distance (6MWD) was obtained by receiver operating characteristic curve (ROC) area under curve (AUC). The postoperative outcome and the occurrence of cardiopulmonary complications in the two groups were analyzed. Results Compared to patients with 6MWD > 449 meters, the age was significantly older (P < 0.001), the forced expiratory volume in the first second (FEV₁) was poor in patients with 6MWD ≤ 449 meters (P < 0.05), and other factors such as surgical resection site, pathological stage, gender, etc., were not significantly different (P > 0.05). The incidence of postoperative cardiopulmonary complications was significantly higher (OR = 2.672, 95%CI 1.488 to 4.798, P = 0.002), and the postoperative extubation time and hospital stay was longer in patients with 6MWD ≤ 449 meters than in patients with 6MWD > 449 meters (P < 0.05). 6MWD ≤ 449 meters was an independent risk factor for postoperative cardiopulmonary complications (OR = 2.395, 95%CI 1.299 to 4.415, P = 0.005). Conclusion As a simple function test, 6MWT can be routinely used to assess the physiological function of patients undergoing pulmonary lobectomy. Patients with 6MWD ≤ 449 meters may be in higher risks of postoperative cardiopulmonary complications.

Key words: six-minute walk test, pulmonary lobectomy, preoperative evaluation

中图分类号:

R734.2

王龙平,杨学宁,曾斌,徐光青. 6分钟步行试验在肺叶切除术患者术前评估中的应用[J]. 《中国康复理论与实践》, 2022, 28(2): 242-248.

WANG Longping,YANG Xuening,ZENG Bin,XU Guangqing. Application of six-minute walk test in preoperative evaluation of patients undergoing pulmonary lobectomy[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2022, 28(2): 242-248.

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项目	诊断标准
心律失常	需要药物干预或心内科会诊
肺部感染	①痰或胸水中查到病原菌; ②患者出现白细胞计数升高(> 12×10⁹ /L)和/或体温> 38°,持续3 d或经抗生素处理后明显下降; ③术后增加或调整抗生素后,症状或体征减轻或消失,白细胞计数明显下降,或者影像学显示浸润灶相应缩小
肺不张	①影像学显示肺不张; ②有呼吸困难表现且在不吸氧情况下血氧饱和度下降至90%以下
皮下气肿	①超过手术侧胸壁的皮下积气; ②皮下积气≥ 15 d; ③需要皮肤切口引流
中到大量胸腔积液	①引流时间≥ 15 d; ②需要再次置管
持续性肺漏气	①持续时间≥ 15 d; ②需要再次置管引流; ③持续负压吸引时间≥ 3 d; ④需手术治疗
乳糜胸	①手术后非血性引流液24 h引流量≥ 500 ml且持续时间≥ 3 d; ②禁食治疗≥ 5 d; ③需要开胸处理
呼吸衰竭	①需要行气管插管; ②需要呼吸机辅助通气; ③需转重症监护室治疗
咯血	①药物治疗无效且持续时间≥ 3 d; ②咳血量1次≥ 30 ml; ③需手术治疗

项目	6MWD > 449 m组(n = 183)	6MWD ≤ 449 m组(n = 91)	χ²/t值	P值
年龄/岁	57.29±10.16	63.1±9.24	-4.592	< 0.001
性别/n			0.434	0.510
男	105	56
女	78	35
FEV₁/L	2.40±0.63	2.22±0.49	2.526	0.012
FEV1/%预测值	90.25±17.56	87.55±16.29	1.225	0.222
FVC/L	2.94±0.75	2.80±0.63	1.595	0.112
FVC/%预测值	96.78±15.54	95.12±15.13	0.841	0.401
6MWD/m	532.25±62.90	389.24±57.02	18.271	< 0.001
切除部位/n
右上肺	58	24	0.820	0.365
右中肺	30	9	2.106	0.147
右下肺	28	14	0.000	0.985
左上肺	39	23	0.545	0.460
左下肺	28	21	2.503	0.114
病理分期/n
ⅠA	55	35	1.947	0.163
ⅠB	46	23	0.001	0.980
ⅡA	31	15	0.009	0.924
ⅡB	33	14	0.300	0.548
ⅢA	18	4	2.436	0.119
ⅢB	0	0

项目	6MWD > 449 m组(n = 183)	6MWD ≤ 449 m组(n = 91)	OR(95%CI)	P值
心肺相关并发症/n	30	30	2.672(1.488~4.798)	0.002
心律失常	3	2	1.348(0.221~8.215)	> 0.999
肺部感染	11	8	1.507(0.584~3.888)	0.394
肺不张	4	6	3.159(0.868~11.489)	0.088
皮下气肿	5	3	1.214(0.284~5.194)	> 0.999
中到大量胸腔积液	3	5	3.488(0.815~14.934)	0.160
持续性肺漏气	4	5	2.602(0.681~9.933)	0.277
乳糜胸	0	1	-	-
呼吸衰竭	0	0	-	-
咯血	0	0	-	-
术后拔管时间/d	1.97±1.95	2.46±1.85		0.045
术后住院时间/d	4.97±2.34	5.36±2.41		0.199
总住院时间/d	10.92±4.72	12.45±5.34		0.016

项目	OR(95%CI)	P值
年龄	0.999(0.967~1.032)	0.963
FEV₁	0.702(0.401~1.231)	0.217
6MWD ≤ 449 m	2.395(1.299~4.415)	0.005