Significance and prospect of preoperative inspiratory muscle training in abdominal surgery
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摘要: 肺部并发症作为腹部手术术后常见的并发症之一，不仅增加了患者的住院时间和住院费用，而且严重影响患者的预后和生活质量。近年来随着手术微创技术及麻醉技术的发展，术后肺部并发症(PPCs)的发生率已有所下降，但其仍然是腹部手术常见的并发症。目前临床上常用的预防PPCs的方法有吹气球、腹式呼吸、缩唇呼吸，但由于这些方法无法设定具体的训练强度，且医护人员无法有效评估患者对于这些方法的掌握程度，使得上述方法的实施和疗效均无法得到保障。有研究表明，术前吸气肌训练(IMT)可提高吸气肌的肌力和耐力，改善患者的肺功能，降低腹部手术患者PPCs的发生率，其优点是可以根据患者情况设定具体的训练强度，也可根据患者病情由低到高逐步提高训练强度，实现个体化训练。然而，当前我国在腹部手术患者IMT方面还处于初步探索阶段，术前IMT缺乏统一规范的运动处方，并且IMT对腹部手术患者PPCs的降低是否有效还存在争议。因此，本文检索了近年来中英文数据库中有关术前IMT对腹部手术患者PPCs影响的文献，以及各大临床注册中心的灰色文献，结合本研究团队正在进行的相关临床试验，对术前IMT在腹部外科中的应用价值进行了综述，旨在从多方面呈现不同研究的角度及观点，以期为临床工作和未来的临床研究提供参考，使更多患者受益。Abstract: Pulmonary complications, as one of the most common complications after abdominal surgery, not only increase the length of hospital stay and hospital costs but also seriously affect the prognosis and quality of life of patients. With the development of minimally invasive surgical techniques and anaesthetic techniques, the incidence of postoperative pulmonary complications (PPCs) has decreased. However, PPCs are still considered common complications after abdominal surgery. The commonly used clinical methods to prevent PPCs include balloon blowing, abdominal breathing and lip reduction breathing. However, the implementation and efficacy of these methods cannot be guaranteed because they cannot be set at a specific training intensity, and healthcare professionals cannot effectively assess the patient' s mastery of these methods. Several studies have shown that preoperative inspiratory muscle training (IMT) can improve the muscle strength and endurance of inspiratory muscles, improve the lung function of patients and reduce the incidence of PPCs in abdominal surgery patients. The advantage is that the specific training intensity can be set according to the patient' s condition, and the training intensity can be gradually increased from low to high according to the patient' s condition to achieve individualised training. However, IMT for abdominal surgery patients in China is still in the initial exploration stage, which deprives the preoperative IMT of unified and standardised exercise prescription. In addition, whether IMT is effective in reducing PPCs in abdominal surgery patients is still controversial. Therefore, in this paper, we searched the literature on the effects of preoperative IMT on PPCs in abdominal surgery patients in Chinese and English databases and the grey literature of major clinical registries and reviewed the value of preoperative IMT in abdominal surgery in combination with relevant clinical trials being conducted by our research team. Our purpose is to present different research perspectives and viewpoints from various aspects, so as to provide reference for clinical work and future clinical research and benefit more patients.
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表 1 IMT在人体各系统中的应用
Table 1. Applications of IMT in various human systems
系统 疾病 IMT结论 呼吸系统 慢性阻塞性肺疾病[12]、新冠肺炎[13]、哮喘[14] 改善术后有氧运动，减少呼吸困难、焦虑和抑郁 循环系统 冠状动脉旁路移植术[15]、心脏瓣膜置换术[16]、Fontan手术[17] 减少胸部手术PPCs的发生，增加6分钟步行距离 消化系统 胃食管反流病[18]、食管切除术[19]、腹部手术[20] 可改善吸气肌的功能 泌尿系统 肾移植术[21] 改善有关生化指标(血红蛋白和血红蛋白) 运动系统 健康老年人[22]、田径[23] 短期IMT可增加肺通气，对运动员的成绩产生积极影响 神经系统 帕金森[24]、脑外伤[25]、脑卒中[26-27] 改善患者的躯干控制、日常活动和生活质量，改善脑卒中患者的躯干控制 免疫系统 多发性硬化症[28] 改善呼吸强度、肺活量参数和呼吸困难 内分泌系统 糖尿病[29] 增加2型糖尿病患者的膈肌力量 注：Fontan手术又称肺动脉下心室旷置术。 
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表 2 IMP训练频率和周期
Table 2. IMP training frequency and period
作者及年份 试验类型 手术部位 训练仪器 起始训练压力 训练周期 训练频率 ONERUP A 2022[35] RCT 结直肠癌 Threshold® 30% MIP 术前2周+术后4周 2次/d，30次呼吸/次 ONERUP A 2020[36] RCT 结直肠癌 Threshold® 30% MIP，阻力递增 术前2周 2次/d，30次呼吸/次 KARLSSON E 2019[37] RCT 直肠癌 Power breathe K3 50% MIP 术前2~3周 1次/d，30次呼吸/次 VALKENET K 2018[19] RCT 食管癌 Threshold® 60% MIP 术前2周 2次/d，30次呼吸/次 ONERUP A 2017[38] RCT 结直肠癌 Threshold® 30% MIP，阻力递增 术前2周 2次/d，30次呼吸/次 SOARES S M 2013[33] RCT 腹部 Threshold® 20% MIP 术前2~3周 2次/周，25 min/次 注：RCT为随机对照试验(randomized controlled trial)；MIP为最大吸气压(maximal inspiratory pressure)。
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表 3 IMT训练效果评价
Table 3. The IMT training effect evaluation
指标 诊断方法 试验结论 PPCs 影像学标准、实验室指标、专科查体 术前IMT可减少手术患者PPCs的发生[20]，且对肺炎和肺不张改善显著[40] 呼吸肌力 呼吸肌力测量仪器 术前IMT可以增加MIP及MEP, 增加吸气肌的力量和耐力[21] 肺功能 肺功能检查 改善肺功能[20] 住院时间/费用 减少患者的住院时间和住院费用[20] 生化指标 红细胞压积、血红蛋白 升高[21] 其他 HADS量表 减少焦虑和抑郁，增加6MWT，提高生活质量[3, 33] 注：MIP为最大吸气压(maximum inspiratory pressure)；MEP为最大呼气压(maximum expiratory pressure)；HADS量表为医院焦虑和抑郁量表(hospital anxiety and depression scale)；6MWT为6分钟步行距离(6 minutes walking distance)。
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