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Higher PEEP improves outcomes in ARDS patients with clinically objective positive oxygenation response to PEEP: a systematic review and meta-analysis
背景與目的
急性呼吸窘迫綜合征（ARDS）患者的死亡率仍然很高，這些患者需要包括高呼氣末正壓（PEEP）的機(jī)械通氣策略。那么高PEEP是否能夠改善ARDS患者的預(yù)后？特別是在PEEP下氧合反應(yīng)有所改善的患者。本研究旨在探討高PEEP對(duì)ARDS患者的影響。
方 法
我們檢索了MEDLINE、CENTRAL、EMBASE、CINAHL和Web of Science等數(shù)據(jù)庫(kù)中1990年1月到2017年12月相關(guān)的隨機(jī)對(duì)照試驗(yàn)（RCT），采用Cochrane推薦的方法對(duì)PEEP對(duì)成年ARDS患者的影響進(jìn)行了Meta分析。
結(jié) 果
共納入來(lái)自9個(gè)隨機(jī)對(duì)照試驗(yàn)（RCT）的3612例患者，高PEEP組1794例，低PEEP組1818例；高PEEP組與低PEEP組住院死亡率無(wú)顯著差異（RR=0.92；95%CI，0.79～1.07；P=0.26）；28天死亡率（RR=0.88；95%CI，0.72至1.07；P=0.19）和ICU死亡率（RR=0.83；95%CI，0.65至1.07；P=0.15）兩組間也無(wú)統(tǒng)計(jì)學(xué)差異；高PEEP組與低PEEP組氣壓傷的危險(xiǎn)性無(wú)顯著差異（RR=1.24；95%CI，0.74～2.09，P=0.41）；在ARDS患者亞組分析中（來(lái)自6個(gè)RCT）， PEEP增加，高PEEP組對(duì)氧合改善作出反應(yīng)的患者醫(yī)院病死率(RR=0.83;95%CI 0.69～0.98;P=0.03)、ICU病死率顯著降低(RR=0.74;95%CI,0.56～0.98;P=0.04),但28d病死率無(wú)明顯下降(RR=0.83;95%CI,0.67～1.01;P=0.07)；與PEEP水平低于10cmH2O（來(lái)自6個(gè)RCT）的低PEEP組ARDS患者比較，高PEEP組的ICU死亡率低于相對(duì)較低（RR=0.65；95%CI，0.45-0.94；P=0.02）。
結(jié) 論
對(duì)于可通過(guò)增加PEEP而改善氧合反應(yīng)的ARDS患者，高PEEP可降低死亡率、ICU死亡率和28天死亡率，且高PEEP不增加氣壓傷的風(fēng)險(xiǎn)。
原始文獻(xiàn)摘要
Guo L, Xie J, Huang Y, et al. Higher PEEP improves outcomes in ARDS patients with clinically objective positive oxygenation response to PEEP: a systematic review and meta-analysis[J]. BMC anesthesiology, 2018.
Background: Mortality in patients with acute respiratory distress syndrome (ARDS) remains high. These patients require mechanical ventilation strategies that include high positive end-expiratory pressure (PEEP). It remains controversial whether high PEEP can improve outcomes for ARDS patients, especially patients who show improvement in oxygenation in response to PEEP. In this meta-analysis, we aimed to evaluate the effects of high PEEP on ARDS patients.
Methods: We electronically searched randomized controlled trials (RCTs) reported in the MEDLINE, CENTRAL,EMBASE, CINAHL and Web of Science databases from January 1990 to December 2017. Meta-analyses of the effects of PEEP on survival in adults with ARDS were conducted using the methods recommended by the Cochrane
Collaboration.
Results: A total of 3612 patients from nine randomized controlled trials (RCTs) were included. There were 1794 and 1818 patients in the high and low PEEP groups, respectively. Hospital mortality showed no significant difference between the high and low PEEP groups (RR = 0.92; 95% CI, 0.79 to 1.07; P = 0.26). Similar results were found for 28-d mortality (RR = 0.88; 95% CI, 0.72 to 1.07; P = 0.19) and ICU mortality (RR = 0.83; 95% CI, 0.65 to 1.07; P = 0.15). The risk of clinically objectified barotrauma was not significantly different between the high and low PEEP groups (RR = 1.24; 95% CI, 0.74 to 2.09, P =0.41). In the subgroup of ARDS patients who responded to increased PEEP by improved oxygenation (from 6 RCTs), high PEEP significantly reduced hospital mortality (RR = 0.83; 95% CI 0.69 to 0.98; P = 0.03), ICU mortality (RR = 0.74; 95% CI, 0.56 to 0.98; P = 0.04),but the 28-d mortality was not decreased(RR = 0.83; 95% CI, 0.67 to 1.01; P = 0.07). For ARDS patients in the low PEEP group who received a PEEP level lower than 10 cmH2O (from 6 RCTs), ICU mortality was lower in the high PEEP group than the low PEEP group (RR = 0.65; 95% CI, 0.45 to 0.94; P =0.02).
Conclusions: For ARDS patients who responded to increased PEEP by improved oxygenation, high PEEP could reduce hospital mortality, ICU mortality and 28-d mortality. High PEEP does not increase the risk of clinically objectified barotrauma.
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貴州醫(yī)科大學(xué)高鴻教授課題組
編輯：王貴龍 審校：李華宇
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