与静脉-静脉体外膜氧合支持下肺移植患者预后相关的呼吸顺应性研究-动脉网

Respiratory compliance related to prognostic of lung transplant patients with veno‑venous extracorporeal membrane oxygenation support

Nature 等信源发布 2025-03-11 22:30

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Abstract

摘要

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) plays an important role in the perioperative care of critically ill lung transplant patients. However, the factors predicting prognosis are unclear. This study assessed the association between static respiratory compliance (Crs) and outcomes of lung transplant patients receiving VV-ECMO in terms of 90-day mortality.

静脉-静脉体外膜肺氧合（VV-ECMO）在危重肺移植患者围手术期护理中起着重要作用。然而，预测预后的因素尚不清楚。本研究评估了静态呼吸顺应性（Crs）与接受VV-ECMO治疗的肺移植患者90天死亡率之间的关联。

Data were retrospectively collected for patients that underwent lung transplantation with VV-ECMO support during 2022–2023. Patients were divided into two groups according to the early postoperative Crs: lower Crs (Crs < 25 ml/cmH.

2022-2023年间，对接受VV-ECMO支持下肺移植的患者进行了回顾性数据收集。根据术后早期Crs值，患者被分为两组：较低Crs组（Crs < 25 ml/cmH）。

O) and higher Crs (Crs ≥ 25 ml/cmH

O) 和更高的 Crs (Crs ≥ 25 ml/cmH

O). Differences in patient characteristics and prognosis were then compared between the two groups. Receiver operating characteristic (ROC) curve analysis was used to evaluate the value of Crs for predicting 90-day mortality and univariate Cox proportional hazard model analysis was performed to estimate risk of Crs.

然后比较两组之间患者特征和预后的差异。采用受试者工作特征（ROC）曲线分析评估Crs预测90天死亡率的价值，并进行单变量Cox比例风险模型分析以估计Crs的风险。

Data were available for a total of 85 patients, including 50 (58.8%) patients in the higher Crs group and 35 (41.2%) patients in the lower Crs group. A lower Crs was significantly associated with a longer postoperative ECMO duration (hours, 42 vs. 24; .

共有85名患者的数据可用，其中高Crs组患者50名（58.8%），低Crs组患者35名（41.2%）。较低的Crs与术后ECMO持续时间较长（小时，42 vs. 24）显著相关。

= 0.022), longer postoperative ventilator time (days, 3.7 vs. 2.0;

= 0.022)，术后呼吸机时间更长（天，3.7 vs. 2.0；

= 0.003), higher application of continuous renal replacement therapy (CRRT) (20.0% vs. 6.0%;

= 0.003)，连续性肾脏替代治疗（CRRT）的应用更高（20.0% vs. 6.0%；

= 0.049), higher incidence of pneumonia (42.9% vs. 20.0%;

= 0.049)，肺炎发生率较高（42.9% vs. 20.0%；

= 0.023), and higher 90-day mortality (22.9% vs. 6.0%;

= 0.023），并且90天死亡率更高（22.9% vs. 6.0%；

= 0.023). The area under the curve of Crs for predicting 90-day mortality was 0.661 (

= 0.023)。Crs预测90天死亡率的曲线下面积为0.661 (

= 0.034). A higher Crs was a protective factor (hazard ratio = 0.925 [0.870–0.984)]

= 0.034）。较高的Crs是保护因素（风险比= 0.925 [0.870–0.984]）

= 0.014). For lung transplant patients receiving VV-ECMO support, Crs < 25 ml/cmH

= 0.014）。对于接受VV-ECMO支持的肺移植患者，Crs < 25 ml/cmH

O is associated with more complications and higher 90-day mortality. As Crs is easily obtained at the bedside, it may be useful for predicting prognosis and guiding patient management.

O与更多的并发症和更高的90天死亡率相关。由于Crs在床边容易获得，它可能对预测预后和指导患者管理有用。

Introduction

介绍

Lung transplantation is an effective procedure for benign end-stage lung disease. However, patients with poor underlying condition are prone to insufficient cardiopulmonary function to maintain the necessary oxygenation and circulatory stability during surgery. Thus, veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a reliable and effective form of support that can expand the patient population suitable for lung transplantation and support the transition to the perioperative period.

肺移植是治疗良性终末期肺病的有效方法。然而，身体状况较差的患者往往因心肺功能不足，难以在手术过程中维持必要的氧合和循环稳定。因此，静脉-静脉体外膜肺氧合（VV-ECMO）是一种可靠且有效的支持方式，可以扩大适合肺移植的患者群体，并帮助过渡到围手术期。

. According to the International Society of Heart and Lung Transplantation, ECMO is performed in 29% of all lung transplants; however, ECMO does not reduce the risk of death

根据国际心肺移植学会的数据，29%的肺移植手术中会使用ECMO，但ECMO并不能降低死亡风险。

. Thus, predictors are needed to indicate prognosis at an early stage to guide clinical practice. Static respiratory compliance (Crs) is a measure that can be easily determined at the bedside. Prior studies have reported a significant correlation between Crs and prognosis in patients with acute respiratory distress syndrome (ARDS) undergoing VV-ECMO.

因此，需要预测指标来在早期阶段指示预后，以指导临床实践。静态呼吸顺应性（Crs）是一种可以在床边轻松确定的指标。先前的研究已经报道了在接受VV-ECMO治疗的急性呼吸窘迫综合征（ARDS）患者中，Crs与预后之间存在显著相关性。

. Primary graft dysfunction (PGD) occurs 72 h after lung transplantation and has many clinical features in common with ARDS

原发性移植物功能障碍 (PGD) 发生在肺移植后 72 小时内，且与 ARDS 有许多共同的临床特征。

. Notably, both PGD and ARDS can affect lung compliance. In this study, we aimed to investigate the relationship between Crs and the prognosis of lung transplant patients with VV-ECMO.

特别是，PGD和ARDS都会影响肺的顺应性。在本研究中，我们旨在调查Crs与使用VV-ECMO的肺移植患者预后之间的关系。

Methods

方法

Study design

研究设计

This retrospective study investigated patients who underwent lung transplantation with VV-ECMO between 2022 and 2023 at the Affiliated Wuxi People’s Hospital of Nanjing Medical University. The inclusion criteria were (1) age > 18 years and (2) underwent lung transplantation with VV-ECMO. The exclusion criteria were (1) lung retransplantation; (2) incomplete Crs records.

这项回顾性研究调查了2022年至2023年在南京医科大学附属无锡人民医院接受VV-ECMO支持下肺移植的患者。纳入标准为：(1) 年龄 > 18岁；(2) 接受VV-ECMO支持下的肺移植。排除标准为：(1) 肺再移植；(2) Crs记录不完整。

Figure .

图。

shows the flow diagram of patients in this study.

显示了本研究中患者的流程图。

Fig. 1

图1

The flow diagram.

流程图。

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This retrospective study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) and approved by the Ethics Commission of the Affiliated Wuxi People’s Hospital of Nanjing Medical University (No. KY24059). Due to the retrospective nature of this study, the need for informed consent was waived by the Committee..

本回顾性研究根据2013年修订的《赫尔辛基宣言》进行，并经南京医科大学附属无锡人民医院伦理委员会批准（编号：KY24059）。由于本研究为回顾性研究，委员会豁免了知情同意的要求。

ECMO strategy

体外膜肺氧合策略

The pre-ECMO evaluation is performed by both surgeons and anesthesiologists according to the Extracorporeal Life Support Organization (ELSO) guidelines

根据体外生命支持组织 (ELSO) 指南，术前 ECMO 评估由外科医生和麻醉师共同进行。

. In cases requiring one-lung ventilation, if the hemodynamics were stable and the percutaneous oxygen saturation (SpO

在需要单肺通气的情况下，如果血流动力学稳定且经皮氧饱和度 (SpO

) was maintained > 90%, ECMO treatment was not considered; if the hemodynamics were stable and SpO

）保持在90%以上，未考虑ECMO治疗；如果血流动力学稳定且SpO

was continuously < 90%, VV-ECMO support was used. VV-ECMO support was established intraoperatively in all cases that met the indications for ECMO.

持续低于90%时，使用了VV-ECMO支持。在所有符合ECMO指征的病例中，VV-ECMO支持均在术中建立。

Peripheral cannulation was the preferred method of support with VV-ECMO. The most common cannulation sites were femoral-internal jugular, with the tip of a femoral drainage cannula at the inferior vena cava-right atrium junction and an internal jugular return cannula with the top either at the superior vena cava-right atrium junction or the right atrium.

外周插管是VV-ECMO支持的首选方法。最常见的插管部位是股静脉-颈内静脉，股静脉引流插管的尖端位于下腔静脉-右心房交界处，颈内静脉回流插管的顶端则位于上腔静脉-右心房交界处或右心房。

ECMO management and weaning were performed following the ELSO guidelines.

ECMO的管理和撤机是按照ELSO指南进行的。

。

Measurement of Crs

测量Crs

Within 2 h of admission to the ICU, patients were in a supine position without spontaneous respiration; otherwise, safe doses of sedative, analgesic, and muscle relaxants were used to prevent spontaneous breathing. Patients received volume-controlled ventilation delivered using a square waveform flow.

在入住ICU后2小时内，患者处于仰卧位且无自主呼吸；否则，使用安全剂量的镇静剂、止痛剂和肌肉松弛剂来防止自主呼吸。患者接受使用方波形流速进行的容量控制通气。

The initial parameter settings were: tidal volume (VT) at 6 mL/kg of predicted body weight (PBW), PBW was calculated as 50 + 0.91 × (height [cm] – 152.4) for men and 45.5 + 0.91× (height [cm] – 152.4) for women, positive end-expiratory pressure (PEEP) at 5 cmH.

初始参数设置为：潮气量 (VT) 为预测体重 (PBW) 的 6 mL/kg，男性 PBW 计算公式为 50 + 0.91 ×（身高 [cm] – 152.4），女性为 45.5 + 0.91 ×（身高 [cm] – 152.4），呼气末正压 (PEEP) 为 5 cmH₂O。

O, respiratory rate (RR) at 12/min. Next, we recorded the plateau pressure (Pplat); Crs was calculated as VT/(Pplat-PEEP). The ventilator parameters during the non-measurement period were set by clinicians according to the lung-protective ventilation strategy and each patient’s condition

氧合指数（O），呼吸频率（RR）为12/分钟。接下来，我们记录了平台压（Pplat）；顺应性（Crs）通过潮气量（VT）除以（平台压-呼气末正压，即Pplat-PEEP）计算得出。在非测量期间，呼吸机参数由临床医生根据肺保护性通气策略和每位患者的状况进行设置。

。

PGD definition

PGD定义

PGD was diagnosed according to the latest recommendation of the ISHLT working group

根据ISHLT工作组的最新建议诊断PGD

. Patients were graded on the basis of the ratio of the partial pressure of oxygen (PaO

患者根据氧分压 (PaO) 的比例进行分级

) to fraction of inspired oxygen (FiO

) 转换为吸入氧气分数 (FiO

) (P/F ratio) and chest radiographs. The PGD grade at index ICU admission (0 h), 24 h, 48 h, and 72 h was assessed. Patients with a chest x-ray indicating pulmonary infiltrates and P/F ratio < 200 were defined as PGD3, while patients on ECMO were defined as PGD3 with any P/F ratio.

）（P/F比值）和胸部X光片。在ICU入院时（0小时）、24小时、48小时和72小时对PGD等级进行了评估。胸部X光显示肺部浸润且P/F比值<200的患者被定义为PGD3，而使用ECMO的患者无论P/F比值如何均被定义为PGD3。

Data collection

数据收集

The following data were collected from the medical records of lung transplant patients: age, body mass index (BMI), gender, primary disease, chronic disease, preoperative cardiopulmonary function and laboratory parameters, Acute Physiology and Chronic Health Evaluation II (APACHEII) score, Sequential Organ Failure Assessment (SOFA) score, cold ischemia time, surgical condition, ventilator parameters and ECMO settings, lac, P/F, and PaCO.

以下数据是从肺移植患者的医疗记录中收集的：年龄、体重指数（BMI）、性别、原发疾病、慢性疾病、术前心肺功能和实验室参数、急性生理与慢性健康状况评分II（APACHEII）、序贯器官衰竭评估（SOFA）评分、冷缺血时间、手术情况、呼吸机参数和ECMO设置、乳酸（lac）、氧合指数（P/F）和动脉二氧化碳分压（PaCO）。

within 2 h after surgery. The primary outcome was 90-day survival after lung transplantation. The secondary outcomes were postoperative ECMO time, postoperative ventilator time, ICU stay, hospital stay, PGD3, continuous renal replacement therapy (CRRT), and pneumonia.

手术后2小时内。主要结局为肺移植后90天存活率。次要结局包括术后ECMO使用时间、术后呼吸机使用时间、ICU停留时间、住院时间、PGD3（原发性移植物功能障碍3级）、连续性肾脏替代治疗（CRRT）和肺炎。

Statistical analysis

统计分析

Normally distributed continuous variables are presented as the mean ± standard deviations and Student’s t test was used for group comparisons. Non-normally distributed continuous variables are presented as the median (interquartile range) and the Mann-Whitney U test was used for group comparisons. Categorical variables are expressed as numbers (percentages) and analyzed using the Chi-square test or Fisher’s exact test.

正态分布的连续变量表示为均值±标准差，并使用Student t检验进行组间比较。非正态分布的连续变量表示为中位数（四分位距），并使用Mann-Whitney U检验进行组间比较。分类变量表示为数量（百分比），并使用卡方检验或Fisher精确检验进行分析。

Receiver operating characteristic (ROC) curve analysis was used to calculate the area under the curve (AUC) values to assess the predictive ability of Crs for 90-day mortality. Cutoff points were calculated by obtaining the best Youden index (sensitivity + specificity − 1). The Kaplan-Meier method was used to plot the cumulative curves of ECMO and mechanical ventilation times between the two groups.

使用受试者操作特征（ROC）曲线分析计算曲线下面积（AUC）值，以评估Crs对90天死亡率的预测能力。通过获取最佳Youden指数（灵敏度+特异性-1）来计算临界点。采用Kaplan-Meier方法绘制两组之间ECMO和机械通气时间的累积曲线。

For the survival analysis, the effect of a lower Crs was assessed using the log-rank test. Univariate Cox regression was used to examine the correlation between Crs and 90-day mortality. Statistical analysis was performed using SPSS 25.0, GraphPad Prism 6.0, and R version 4.3.0 with the KMsurv, survival, and survminer packages.

在生存分析中，使用对数秩检验评估了较低的Crs的影响。采用单变量Cox回归分析Crs与90天死亡率之间的相关性。统计分析使用SPSS 25.0、GraphPad Prism 6.0以及R 4.3.0版本进行，并使用了KMsurv、survival和survminer软件包。

Results with a two-tailed P value < 0.05 were considered to be statistically significant..

结果中双尾P值<0.05被认为具有统计学显著性。

Results

结果

Clinical characteristics

临床特征

Data were available for a total of 85 lung transplant patients who received VV-ECMO. In the ROC analysis, the AUC of Crs for predicting 90-day mortality was 0.661 (

共有85名接受VV-ECMO的肺移植患者的数据可用。在ROC分析中，Crs预测90天死亡率的AUC为0.661（

= 0.034). The best Youden index was obtained when Crs = 25 ml/cmH

= 0.034）。当Crs = 25 ml/cmH时，获得了最佳的Youden指数。

O. Based on Crs values, patients were assigned to the higher Crs group (

根据Crs值，患者被分配到较高的Crs组（

= 50, 58.8%) or lower Crs group (

= 50, 58.8%) 或较低的 Crs 组 (

= 35, 41.2%). As shown in Table

= 35, 41.2%）。如表中所示

, there were no significant group differences in the baseline data (

，基线数据中没有显著的组间差异 (

> 0.05)。.

Table 1 Cohort characteristics.

表1 队列特征。

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Postoperative outcomes

术后结果

Compared to the higher Crs group, the lower Crs group had a higher driving pressure (14 ± 1.2 vs. 12 ± 0.8 cmH

与高Crs组相比，低Crs组的驱动压力更高（14 ± 1.2 vs. 12 ± 0.8 cmH）。

哦，

<0.001) and Pplat (20 ± 1.3 vs. 18 ± 1.1 cmH

<0.001）和Pplat（20±1.3 vs. 18±1.1 cmH

哦，

= 0.015). There were no significant group differences in terms of ventilator parameter settings or VV-ECMO flow rates at the initial postoperative procedure (Table

= 0.015)。在术后初期的呼吸机参数设置或VV-ECMO流量方面，组间无显著差异（表

). Figure

`). 图`

A shows the change in P/F over time. The P/F at 24 h was higher than that at 0 h, while the 48 h and 72 h P/F values tended to be stable. Compared to the lower Crs group, the higher Crs group had a higher 0 h P/F (274 ± 39.3 vs. 197 ± 33.1,

A显示了P/F随时间的变化。24小时的P/F高于0小时，而48小时和72小时的P/F值趋于稳定。与低Crs组相比，高Crs组的0小时P/F更高（274±39.3 vs. 197±33.1）。

= 0.006) and 24 h P/F (348 ± 28.2 vs. 259 ± 23.9,

= 0.006) 和 24 小时 P/F (348 ± 28.2 对 259 ± 23.9，

<0.001). Moreover, the higher Crs group had a lower 0 h PaCO

<0.001）。此外，较高Crs组的0小时PaCO较低

(32.5 ± 1.9 vs. 38.2 ± 3.6 mmHg,

= 0.003) and 24 h PaCO

= 0.003) 和 24 小时 PaCO

(35.9 ± 2.1 vs. 39.7 ± 2.6 mmHg,

= 0.020) compared to the lower Crs group, as shown in Fig.

= 0.020)，与较低的Crs组相比，如图所示。

Table 2 Postoperative data and observed outcomes.

表2 术后数据及观察结果。

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Fig. 2

图2

P/F recorded from 0 h to 72 h in two groups;

两组从0小时到72小时记录的P/F；

PaCO

recorded from 0 h to 72 h in two groups.

从0小时到72小时在两组中记录。

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For all patients, the 24 h, 48 h, and 72 h PGD proportions were 51.8%, 35.3%, and 31.8%, respectively. The incidence of grade 3 PGD at 48 h was significantly lower than that at 24 h (

所有患者中，24小时、48小时和72小时的PGD比例分别为51.8%、35.3%和31.8%。48小时时3级PGD的发生率显著低于24小时时的发生率（

= 0.030); however, there was no significant difference between 72 h and 48 h (Fig.

= 0.030)；然而，72小时和48小时之间没有显著差异（图。

). The lower Crs group tended to include more patients with 24 h PGD3 (

）。较低的Crs组倾向于包括更多24小时PGD3患者（

= 0.087). Compared with the higher Crs group, the lower Crs group had increased pneumonia (42.9% vs. 20.0%,

= 0.087）。与高Crs组相比，低Crs组的肺炎发生率增加（42.9% vs. 20.0%，

= 0.023), CRRT (20.0% vs. 6.0%,

= 0.023)，CRRT（20.0% 对 6.0%，

= 0.049), postoperative ECMO time (42 h vs. 24 h,

= 0.049)，术后ECMO时间（42小时 vs. 24小时，

= 0.022), and postoperative MV time (3.7 days vs. 2.0 days,

= 0.022），术后机械通气时间（3.7天 vs. 2.0天，

= 0.003) and decreased 90-day survival (77.1% vs. 94.0%,

= 0.003）并降低了90天生存率（77.1% vs. 94.0%，

= 0.023).

= 0.023)。

Fig. 3

图 3

Proportion of postoperative PGD3 occurrence at 24 h, 48 h and 72 h.

术后24小时、48小时和72小时PGD3发生率。

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The cumulative curve of ECMO weaning and MV showed a significant difference between the two groups (Fig.

ECMO脱机和机械通气的累积曲线显示两组之间存在显著差异（图。

). The difference in K-M survival curves between the lower and higher Crs groups was statistically significant (

）。较低和较高Crs组之间的K-M生存曲线差异具有统计学意义（

= 0.023, Fig.

= 0.023，图。

）

Fig. 4

图4

Postoperative ECMO time curves in two groups ;

两组术后ECMO时间曲线；

Ventilator time curves in two groups.

两组的呼吸机时间曲线。

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Fig. 5

图5

Kaplan–Meier survival curves in patients.

患者的Kaplan-Meier生存曲线。

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The effect of Crs remained significant in the univariate Cox regression model [HR 0.925 (0.870–0.984),

在单变量 Cox 回归模型中，Crs 的效应仍然显著 [HR 0.925 (0.870–0.984)，

= 0.014], indicating that higher Crs was a protective factor for 90-day mortality.

= 0.014]，表明较高的Crs是90天死亡率的保护因素。

Discussion

讨论

VV-ECMO during lung transplantation is considered a safe and effective form of life support that is increasingly used

肺移植期间使用VV-ECMO被认为是一种安全有效的生命支持形式，并且其使用日益增多。

. Critically ill patients often require ECMO support due to preoperative respiratory failure, pulmonary hypertension, or cardiac dysfunction during lung transplantation

危重病患者常常因为术前呼吸衰竭、肺动脉高压或肺移植期间的心脏功能障碍而需要ECMO支持。

. The V-V mode offers a main pulmonary support effect

V-V模式提供主要的肺部支持效果

. ECLS has reported survival rates of 56–100% for ECMO support as a bridge to lung transplantation

体外生命支持组织报告称，作为肺移植过渡支持的体外膜肺氧合存活率为56%-100%。

，

. The use of ECMO for intraoperative support management varies considerably across centers across the world. Its use in the perioperative setting of lung transplantation is associated with favorable outcomes

体外膜肺氧合（ECMO）在术中支持管理中的应用在世界各地的中心差异很大。其在肺移植围手术期的应用与良好的结果相关。

. Christian et al. reported that ECMO as a bridge to lung transplantation is associated with higher perioperative mortality, but acceptable mid-term survival, in carefully selected patients

克里斯蒂安等人报告称，对于经过仔细筛选的患者，将ECMO作为肺移植的过渡手段与较高的围手术期死亡率相关，但中期生存率可以接受。

. In another larger study, Ius et al. found no differences in long-term complications or outcomes in ECMO recipients

在另一项更大规模的研究中，Ius 等人发现 ECMO 接受者在长期并发症或结果方面没有差异。

. Sef et al. reported a similar 30-day mortality between bridge to transplantation and non‐bridge to transplantation patients (4.6% vs. 6.6%,

Sef 等人报告了移植过渡患者和非移植过渡患者之间相似的30天死亡率（4.6% 对 6.6%，

= 0.083) despite a higher incidence of early postoperative complications (e.g., need for ECMO, delayed chest closure, and acute kidney injury)

= 0.083），尽管早期术后并发症（如需要ECMO、延迟关胸和急性肾损伤）的发生率较高。

. In their study, the 90-day survival rate of patients treated with VV-ECMO lung transplantation was 87%. Takahashi et al. retrospectively analyzed clinical data of 204 patients with PGD3 after lung transplantation from 2010 to 2020, finding no significant survival difference between patients with and without perioperative ECMO.

在他们的研究中，使用VV-ECMO治疗的肺移植患者90天存活率为87%。高桥等人回顾性分析了2010年至2020年间204名肺移植后出现PGD3的患者的临床数据，发现术中或术后使用ECMO的患者与未使用的患者之间存活率没有显著差异。

Thus, the authors concluded that perioperative ECMO did not increase the risk of mortality.

因此，作者得出结论：围手术期 ECMO 并未增加死亡风险。

. Zhao et al. reported that the use of intraoperative ECMO support reduced ischemia-reperfusion injury due to the avoidance of hyperperfusion in double sequential or lobar lung transplantation, improved surgical exposure and reduced operative time

赵等人报道，在双序贯或肺叶移植中使用术中ECMO支持减少了因避免过度灌注导致的缺血再灌注损伤，改善了手术视野并缩短了手术时间。

. Notably, the donor lung is prone to the development of pulmonary edema by ischemia reperfusion injury. Prolonging the use of VV-ECMO thus enables “lung rest” and restoration of lung function. ECMO respiratory support reduces lung injury by ultraprotective lung ventilation strategies and the potential harm of high FiO.

特别是，供体肺容易因缺血再灌注损伤而发生肺水肿。因此，延长VV-ECMO的使用能够实现“肺休息”和肺功能的恢复。ECMO呼吸支持通过超保护性肺通气策略和高FiO可能带来的伤害，减少了肺损伤。

to lungs in PGD3 patients. During the postoperative period, ECMO may also affect right ventricular afterload by reducing pulmonary resistance. ECMO may reduce the pulmonary edema on lung injury to lower the PGD grade. A previous controlled study at our center found that delayed VV-ECMO weaning was associated with lower complications and shorter hospital stay.

在PGD3患者中，ECMO对肺部也起到保护作用。在术后阶段，ECMO还可能通过降低肺阻力来影响右心室的后负荷。ECMO可以减轻肺损伤引起的肺水肿，从而降低PGD的严重程度。我们中心之前的一项对照研究发现，延迟VV-ECMO撤机与较低的并发症发生率和较短的住院时间相关。

. However, delayed ECMO weaning will impact the incidence of PGD3 at 0 h. Thus, further research is needed to analyze ECMO strategies in lung transplantation patients.

然而，延迟的ECMO脱机将影响PGD3在0小时的发生率。因此，需要进一步研究来分析肺移植患者的ECMO策略。

The main findings of the present study are that, using Crs = 25 ml/cmH

本研究的主要发现是，使用Crs = 25 ml/cmH

O as the cut-off point, the lower Crs group had a longer ECMO time, longer MV time, higher incidence of complications, and decreased 90-day survival rate, suggesting that Crs might be a prognostic factor. Notably, there are relatively few known prognostic factors for lung transplantation patients with VV-ECMO support.

以O为临界点，较低的Crs组表现出更长的ECMO时间、更长的机械通气时间、更高的并发症发生率以及降低的90天生存率，这表明Crs可能是一个预后因素。值得注意的是，对于接受VV-ECMO支持的肺移植患者，已知的预后因素相对较少。

. As Crs is easily measured at the bedside, increased clinical attention and management of patients with lower Crs may improve outcomes. In a study of COVID-19 patients with VV-ECMO divided into three groups based on Crs (Crs ≤ 11 cmH

由于Crs在床边容易测量，加强对低Crs患者的临床关注和管理可能会改善预后。在一项针对使用VV-ECMO的COVID-19患者的研究中，根据Crs（Crs ≤ 11 cmH）将患者分为三组。

O, Crs 11–20 cmH

O，Crs 11–20 cmH

O, and Crs >20 cmH

O，且 Crs >20 cmH

O), Crs was associated with 180-day survival

O)，Crs 与 180 天生存率相关

. PGD is an acute lung injury due to ischemia-reperfusion during lung transplantation. The incidence of patients with ECMO was further increased, with 57% of patients developing PGD3 within 72 h after surgery

PGD是由于肺移植过程中缺血再灌注引起的急性肺损伤。使用ECMO的患者发生率进一步增加，57%的患者在术后72小时内发展为PGD3。

. PGD shares many clinical features and radiographic findings with ARDS, including decreased lung function, increased elastic resistance, and ventilation/flow imbalance

PGD与ARDS有许多共同的临床特征和影像学表现，包括肺功能下降、弹性阻力增加以及通气/血流失衡。

. Decreased lung compliance results in low PaO

肺顺应性降低会导致低PaO

and decreased excretion of CO

并减少CO的排泄

, which delay the weaning of ECMO and MV and increase the incidence of ventilator-associated pneumonia and other complications

，延迟了ECMO和MV的撤机过程，并增加了呼吸机相关性肺炎及其他并发症的发生率

. Patients with lower Crs are more susceptible to ventilator-associated lung injury, even when low-tidal volume lung protective ventilation is used

较低Crs的患者即使使用小潮气量肺保护性通气，也更容易受到呼吸机相关性肺损伤。

. Ischemia reperfusion injury is not only a risk factor for PGD, but can also lead to inflammatory damage in other organs, and the kidney, one of the affected organs, is prone to acute kidney injury. In addition, the use of nephrotoxic drugs also increases the incidence of acute kidney injury in lung transplantation.

缺血再灌注损伤不仅是PGD的危险因素，还可导致其他器官的炎症损伤，其中肾脏作为受影响的器官之一，容易发生急性肾损伤。此外，肾毒性药物的使用也增加了肺移植后急性肾损伤的发生率。

These high-risk factors will require increased use of CRRT.

这些高危因素将需要增加CRRT的使用。

. These risk factors can interact, further affecting prognosis. In the present study, there was no significant difference between groups in the incidence of PGD3 at 24 h, 48 h, and 72 h. There are several possible explanations for this finding. Different PGD phenotypes may have had different effects on lung compliance.

这些风险因素可以相互作用，进一步影响预后。在本研究中，各组之间在 24 小时、48 小时和 72 小时时 PGD3 的发生率没有显著差异。对于这一发现有几种可能的解释。不同的 PGD 表型可能对肺顺应性有不同的影响。

Alternatively, it may relate to the sample size. The incidence of PGD3 in the two groups gradually approached similar levels over time, which might relate to PGD treatment and progression. The lower Crs group showed a delayed rise in P/F and a high initial carbon dioxide content. Although there were differences between P/F and carbon dioxide, the overall trend was similar.

或者，这可能与样本量有关。两组中 PGD3 的发生率随着时间的推移逐渐接近相似水平，这可能与 PGD 的治疗和进展有关。较低的 Crs 组表现出 P/F 延迟上升和较高的初始二氧化碳含量。尽管 P/F 和二氧化碳之间存在差异，但总体趋势相似。

Future studies should explore whether different PGD phenotypes can be distinguished according to Crs in order to provide individualized clinical management, and the relationship between changes in Crs and PGD warrants further research..

未来的研究应探讨是否可以根据Crs区分不同的PGD表型，以提供个性化的临床管理，Crs变化与PGD之间的关系也值得进一步研究。

Our study is subject to several limitations. First, it is a retrospective single-center study. Although the lung transplantation capacity of our center is relatively high, multi-center validation is needed. Second, the dynamic change in lung compliance was not monitored. The relationship between dynamic change and prognosis should be further studied.

本研究存在几个局限性。首先，这是一项回顾性的单中心研究。虽然本中心的肺移植能力较高，但仍需要多中心验证。其次，未监测肺顺应性的动态变化，应进一步研究动态变化与预后的关系。

Third, as data on donor lungs were not collected, we cannot exclude the influence of donor lungs on prognostic confounding factors. Fourth, as ventilatory management of lung transplantation patients was relatively individualized, this may have influenced outcomes..

第三，由于未收集供体肺部的数据，我们无法排除供体肺部对预后混杂因素的影响。第四，由于肺移植患者的通气管理相对个体化，这可能会影响结果。

Conclusions

结论

In lung transplant patients with VV-ECMO support, Crs < 25 ml/cmH

在使用VV-ECMO支持的肺移植患者中，Crs < 25 ml/cmH

O is associated with higher complications and 90-day mortality. Furthermore, the lower Crs group tended to have an increased incidence of PGD3. The use of Crs, which is easily accessible at the bedside, may help predict prognosis and guide patient management. The relationship between Crs and the prognosis of lung transplantation patients with VV-ECMO needs to be confirmed through multi-center prospective studies in the future..

O 与较高的并发症和 90 天死亡率相关。此外，较低的 Crs 组往往有更高的 PGD3 发生率。Crs 在床旁易于获取，其使用可能有助于预测预后并指导患者管理。Crs 与使用 VV-ECMO 的肺移植患者预后之间的关系未来需要通过多中心前瞻性研究来确认。

Data availability

数据可用性

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

当前研究中使用和分析的数据集可根据合理要求从通讯作者处获取。

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Funding

资金筹集

No funding was received to assist with the preparation of this manuscript.

本稿件的撰写未获得任何资金支持。

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Authors and Affiliations

作者与所属机构

Wuxi Medical Center, The Affiliated Wuxi People’S Hospital of Nanjing Medical University, Wuxi, 214023, Jiangsu, China

中国江苏省无锡市南京医科大学附属无锡人民医院，无锡医疗中心，邮编214023

Chenhao Xuan, Jingxiao Gu & Hongyang Xu

宣晨浩，顾靖霄，徐鸿洋

Wuxi Lung Transplant Center, The Affiliated Wuxi People’S Hospital of Nanjing Medical University, Wuxi, 214023, Jiangsu, China

中国江苏无锡市南京医科大学附属无锡人民医院无锡肺移植中心，邮编214023

Jingyu Chen

陈静宇

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谷歌学术

Hongyang Xu

徐鸿洋

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谷歌学术

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Hongyang Xu, Jingyu Chen, and Chenhao Xuan participated in the design of the study. Chenhao Xuan wrote the application for the ethical approval. Chenhao Xuan collected the data. Chenhao Xuan and Jingxiao Gu analyzed the data. Chenhao Xuan drafted the manuscript. Chenhao Xuan prepared Figs. 1, 2, 3, 4 and 5; Table 1, and 2.

徐洪阳、陈静宇和轩晨浩参与了研究的设计。轩晨浩撰写了伦理审批申请。轩晨浩收集了数据。轩晨浩和顾靖霄分析了数据。轩晨浩起草了手稿。轩晨浩准备了图1、2、3、4和5；表1和2。

All authors read and approved the final manuscript..

所有作者阅读并批准了最终稿件。

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Hongyang Xu

徐鸿洋

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Competing interests

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The authors declare no competing interests.

作者声明不存在竞争性利益。

Ethics approval and consent to participate

伦理批准与参与同意

This retrospective study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) and approved by Ethics Commission of the Affiliated Wuxi People’s Hospital of Nanjing Medical University (No. KY24059), and the need for informed consent was waived by the Committee due to the retrospective nature of this study..

本回顾性研究根据2013年修订的《赫尔辛基宣言》进行，并经南京医科大学附属无锡人民医院伦理委员会批准（编号：KY24059），由于本研究为回顾性研究，委员会豁免了知情同意的要求。

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You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

根据本许可，您无权分享从本文或其部分内容衍生的改编材料。本文中的图像或其他第三方材料包含在文章的Creative Commons许可中，除非在材料的署名行中另有说明。如果材料未包含在文章的Creative Commons许可中，并且您的预期用途不被法律规定允许或超出了允许的使用范围，您需要直接从版权持有人处获得许可。

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Xuan, C., Gu, J., Chen, J.

宣，C.，顾，J.，陈，J.