高呼气末正压通气结合小潮气量对急性肺损伤/急性呼吸窘迫综合征患者预后影响的荟萃分析

目的 系统评价高呼气末正压(PEEP)与低PEEP机械通气对急性肺损伤/急性呼吸窘迫综合征(ALI/ARDS)患者预后的影响.方法 通过检索美国<医学索引>、荷兰<医学文摘>、Cochrane临床试验数据库、中国生物医学文献数据库(CBM)和中国期刊网全文数据库(CNKI)等文献数据库,全面收集全世界范围内高PEEP与低PEEP治疗ALI/ARDS患者的随机对照试验(RCT),提取文献中的相关资料和评估方法学质量,而后采用Cochrane协作网RevMan 5.0软件对资料进行荟萃分析(Meta分析).结果 最终纳入6个RCT共2484例ALI/ARDS患者.A亚组的3个RCT中试验组采用了高PEEP(相对于对照组),对照组采用了低PEEP(相对于试验组),两组均采用了小潮气量(6 ml/kg)通气;B亚组的3个RCT中试验组采用了高PEEP加小潮气量,对照组采用了低PEEP加传统潮气量通气.合并结果显示,B亚组中高PEEP加小潮气量通气策略可以降低患者的28 d病死率Peto比值比(OR)=0.40,95%可信区间(95%CI)0.22～0.72,P=0.003]和气压伤发生率(OR=0.20,95%CI 0.05～0.82,P=0.02);A亚组中,两组患者的28 d病死率(OR=0.86,95%CI 0.72～1.02,P=0.08)和气压伤发生率(OR=1.19,95%CI 0.89～1.58,P=0.25)差异无统计学意义.结论 高PEEP加小潮气量通气可以改善ALI/ARDS患者的28 d病死率和气压伤发生率,单独高PEEP的作用需要进一步评价.

Abstract：

Objective To compare the effects of high and low positive end-expiratory pressure (PEEP) levels on prognosis of patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS). Methods The data in PubMed, EMbase, Cochrane Library, CBM and CNKI were retrieved. All randomized controlled trials (RCTs) of treatment of ALI/ARDS with PEEP with high or low level were included. Study selection and assessment, data collection and analyses were undertaken by two independent reviewers. Meta-analyses were done using Cochrane Collaboration's RevMan 5.0 software.Results Six RCTs, involving a total of 2 484 patients of ALI/ARDS were included in the review. According to ventilation strategy, all trials were divided into subgroup A (high PEEP+low tidal volume of 6 ml/kg vs.low PEEP+low tidal volume) and subgroup B (high PEEP+low tidal volume vs. low PEEP+traditional tidal volume). In subgroup B, there were three RCTs, and high PEEP was found to be associated with a lower 28-day mortality odds ratio (OR)=0. 40, 95% confidence interval (95%CI) 0.22 -0.72, P=0.003]and a lower barotraumas (OR = 0.20,95%CI 0.05 - 0.82, P = 0.02) in patients with ALI/ARDS. In subgroup A, there were three RCTs, and it was found that the differences in 28-day mortality (OR=0.86,95%CI 0.72 - 1.02, P = 0.08) and barotraumas (OR = 1.19, 95%CI 0.89 - 1.58, P= 0.25) were not significant. Conclusion As compared with conventional ventilation, high PEEP and low tidal volume ventilation are associated with improved survival and a lower rate of barotrauma in patients with ALI/ARDS.It is necessary to further confirm the role of high PEEP only in the ventilation strategy in patients with ALI/ARDS.

The influence of high positive end-expiratory pressure ventilation combined with low tidal volume on prognosis of patients with acute lung injury/acute respiratory distress syndrome: a Meta-analysis

Objective To compare the effects of high and low positive end-expiratory pressure (PEEP) levels on prognosis of patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS). Methods The data in PubMed, EMbase, Cochrane Library, CBM and CNKI were retrieved. All randomized controlled trials (RCTs) of treatment of ALI/ARDS with PEEP with high or low level were included. Study selection and assessment, data collection and analyses were undertaken by two independent reviewers. Meta-analyses were done using Cochrane Collaboration's RevMan 5.0 software.Results Six RCTs, involving a total of 2 484 patients of ALI/ARDS were included in the review. According to ventilation strategy, all trials were divided into subgroup A (high PEEP+low tidal volume of 6 ml/kg vs.low PEEP+low tidal volume) and subgroup B (high PEEP+low tidal volume vs. low PEEP+traditional tidal volume). In subgroup B, there were three RCTs, and high PEEP was found to be associated with a lower 28-day mortality odds ratio (OR)=0. 40, 95% confidence interval (95%CI) 0.22 -0.72, P=0.003]and a lower barotraumas (OR = 0.20,95%CI 0.05 - 0.82, P = 0.02) in patients with ALI/ARDS. In subgroup A, there were three RCTs, and it was found that the differences in 28-day mortality (OR=0.86,95%CI 0.72 - 1.02, P = 0.08) and barotraumas (OR = 1.19, 95%CI 0.89 - 1.58, P= 0.25) were not significant. Conclusion As compared with conventional ventilation, high PEEP and low tidal volume ventilation are associated with improved survival and a lower rate of barotrauma in patients with ALI/ARDS.It is necessary to further confirm the role of high PEEP only in the ventilation strategy in patients with ALI/ARDS.