Intraoperative ventilation strategies to prevent postoperative pulmonary complications: a network meta-analysis of randomised controlled trials
Intraoperative ventilation strategies to prevent postoperative pulmonary complications: a network meta-analysis of randomised controlled trials
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DOI：
10.1016/j.bja.2019.10.024
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发表时间：
2020-03-01
影响因子：
9.8
通讯作者：
Xu, Miao
中科院分区：
文献类型：
--
作者：
Deng, Qi-Wen;Tan, Wen-Cheng;Xu, Miao
背景：关于外科患者肺保护性通气策略的争论正在进行中。有证据表明，使用低潮气量VT可改善临床结果。然而，纳入低VT通气的PEEP和复吸策略（RM）的最佳水平仍不清楚。方法：检索多个电子数据库，以确定关注外科患者低VT策略与常规机械通气（CMV）或两种不同低VT策略之间比较的随机对照试验。主要结局为术后肺部并发症（PPCs）。次要结局是肺不张、肺炎、急性呼吸窘迫综合征和短期死亡率。使用WinBUGS进行贝叶斯网络元分析。估计比值比（ORs）和相应的95%可信区间（CrIs）。结果：与CMV相比，中高PEEP低V-T通气降低了PPCs的风险（中度PEEP [5-8 cm H2O]: OR 0.50 [95% CrI: 0.28, 0.89]；中度PEEP+RMs: 0.39[0.19, 0.78]；高PEEP [>= 9 cm H2O]+RMs: 0.34[0.14, 0.79]）。与CMV相比，中至高PEEP和RMs的低V-T通气也特别降低了肺不张的风险（中度PEEP+RMs: OR 0.36 [95% CrI: 0.16, 0.87]；高PEEP+RMs: 0.41[0.15, 0.97]），而中度PEEP的低V-T通气在降低肺炎风险方面优于CMV （OR 0.46 [95% CrI: 0.15, 0.94]）。结论：低V-T通气和中高PEEP （>= 5 cm H2O）的组合似乎对全麻手术患者具有肺保护作用。
Background: The debate on lung-protective ventilation strategies for surgical patients is ongoing. Evidence suggests that the use of low tidal volume VT improves clinical outcomes. However, the optimal levels of PEEP and recruitment manoeuvre (RM) strategies incorporated into low VT ventilation remain unclear.Methods: Several electronic databases were searched to identify RCTs that focused on comparison between low VT strategy and conventional mechanical ventilation (CMV), or between two different low VT strategies in surgical patients. The primary outcome was postoperative pulmonary complications (PPCs). The secondary outcomes were atelectasis, pneumonia, acute respiratory distress syndrome, and short-term mortality. Bayesian network meta-analyses were performed using WinBUGS. The odds ratios (ORs) and corresponding 95% credible intervals (CrIs) were estimated.Results: Compared with CMV, low V-T ventilation with moderate-to-high PEEP reduced the risk of PPCs (moderate PEEP [5-8 cm H2O]: OR 0.50 [95% CrI: 0.28, 0.89]; moderate PEEP+RMs: 0.39 [0.19, 0.78]; and high PEEP [>= 9 cm H2O]+RMs: 0.34 [0.14, 0.79]). Low V-T ventilation with moderate-to-high PEEP and RMs also specifically reduced the risk of atelectasis compared with CMV (moderate PEEP+RMs: OR 0.36 [95% CrI: 0.16, 0.87]; and high PEEP+RMs: 0.41 [0.15, 0.97]), whilst low V-T ventilation with moderate PEEP was superior to CMV in reducing the risk of pneumonia (OR 0.46 [95% CrI: 0.15, 0.94]).Conclusions: The combination of low V-T ventilation and moderate-to-high PEEP (>= 5 cm H2O) seems to confer lung protection in surgical patients undergoing general anaesthesia.