背景:医用胸膜镜检查(MP)是一种侵入性技术,可通过刚性或半刚性工作仪器进入胸膜腔,允许可视化和获取活检胸膜样本。出于安全原因,仍在使用基于肺科医师的分析来进行胸腔镜检查。这项现实生活中的研究的目的是证明在呼吸重症监护病房(RICU)和介入性肺科重症患者管理方面专长的肺科医师团队在平衡麻醉镇静下进行MP的安全性和诊断率。胸外科医师团队在基于麻醉医师的镇静下进行视频辅助胸外科(VATS)。
方法:在这项多中心回顾性对照研究中,纳入标准是在2017-2022年期间,年龄超过18岁且诊断不明的胸腔积液患者连续入住阿雷佐圣多纳托医院肺科和RICU(意大利,托斯卡纳)和锡耶纳(意大利,托斯卡纳)接受,分别,由肺科医师小组(A组)提供的基于丙泊酚的平衡麻醉下对自主呼吸进行局部麻醉,和VATS由外科医师团队在基于丙泊酚的麻醉镇静下提供,麻醉医师通过气管插管(ETI)使用有创机械通气(IMV)进行管理(B组).主要终点是(1)两组在胸腔积液诊断率方面的比较,(2)胸腔镜手术的主要和次要并发症。次要终点是(1)胸腔镜手术时间;(2)住院时间;(3)丙泊酚剂量;(4)使用视觉模拟评分(VAS)评估手术后患者的舒适度。
结果:我们在A组中招募了91例患者,在B组中招募了116例患者。A组的97.8%与A组的结果一致。100%B组(p=0.374)。恶性积液在A组中诊断为59.3%,在B组中诊断为55.1%;p=0.547。A组未观察到术中或术后死亡事件或主要并发症。B组观察到的主要并发症为3例主要出血事件(p=0.079)和1例与介入手术无关(p=0.315)。在次要并发症方面,两组之间没有显着差异。A组的干预持续时间明显较低(40.0min±12.6vs51.5±31.0;p=0.001)。疼痛控制和,因此,A组患者舒适度较好,平均VAS为0.34±0.65对2.58±1.26,p<0.001。B组住院时间较低(5.1±2.6vs.15.5±8.0,p<0.001)。A组丙泊酚的平均总剂量显著较低(65.6±35.8mg对280±20.0mg;p<0.001)。
结论:这项实际研究表明,由独立的肺炎专家团队在基于丙泊酚的麻醉下进行MP是一种安全且耐受性良好的手术,诊断结果和并发症发生率与VATS相似。
BACKGROUND: Medical pleuroscopy (MP) is an invasive technique that provides access to the pleural space with a rigid or semi-rigid work instrument, allowing for visualization and the obtaining of bioptic pleural samples. Using
pulmonologist-based analgosedation to perform pleuroscopy is still debated for safety reasons. The aim of this real-life study is to demonstrate the safety and diagnostic yield of MP performed under balanced analgosedation by a
pulmonologist team with expertise in the management of critically ill patients in the respiratory intensive care unit (RICU) and interventional pulmonology unit as compared to video-assisted thoracic surgery (VATS) performed by a thoracic surgeon team under anesthesiologist-based analgosedation.
METHODS: In this multicentric retrospective controlled study, the inclusion criteria were patients older than 18 years old with pleural effusion of unknown diagnosis consecutively admitted in the years 2017-2022 to the pulmonology unit and RICU of San Donato Hospital in Arezzo (Italy, Tuscany) and to the thoracic surgery unit of Santa Maria Le Scotte in Siena (Italy, Tuscany) to undergo, respectively, MP under balanced propofol-based analgosedation on spontaneous breathing with local anesthesia provided by a
pulmonologist team (Group A), and VATS provided by a surgeon team under propofol-based analgosedation managed by an anesthesiologist using invasive mechanical ventilation (IMV) via endotracheal intubation (ETI) (Group B). The primary endpoints were (1) a comparison between the two groups in terms of the diagnostic yield of pleural effusion, and (2) major and minor complications of pleuroscopic procedures. The secondary endpoints were (1) the length of the pleuroscopic procedure; (2) the duration of hospitalization; (3) propofol doses; and (4) the patient\'s comfort after the procedure assessed using the Visual Analogue Scale (VAS).
RESULTS: We enrolled 91 patients in Group A and 116 patients in Group B. A conclusive diagnosis was obtained in 97.8% of Group A vs. 100% of Group B (p = 0.374). Malignant effusion was diagnosed in 59.3% of Group A and in 55.1% of Group B; p = 0.547. No intraoperative or postoperative mortality events or major complications were observed in Group A. The major complications observed in Group B were three major bleeding events (p = 0.079) and one exitus (p = 0.315) not related to the interventional procedure. No significant difference emerged between the two groups in terms of minor complications. The duration of the intervention was significantly lower in Group A (40.0 min ± 12.6 versus 51.5 ± 31.0; p = 0.001). Pain control and, therefore, patient comfort were better in Group A, with an average VAS of 0.34 ± 0.65 versus 2.58 ± 1.26, p < 0.001. The duration of hospitalization was lower in Group B (5.1 ± 2.6 vs. 15.5 ± 8.0, p < 0.001). The average overall dose of propofol administered was significantly lower in Group A (65.6 ± 35.8 mg versus 280 ± 20.0 mg; p < 0.001).
CONCLUSIONS: This real-life study shows that the MP performed under propofol-based analgosedation by an independent pneumologist team is a safe and well-tolerated procedure with a diagnostic yield and complication rates similar to those obtained with VATS.