Agarwal Ritesh, Aggarwal Ashutosh N, Gupta Dheeraj, Jindal Surinder K
Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India.
Respir Care. 2007 Nov;52(11):1472-9.
There is a need for an intervention that prevents re-intubation in patients who have been weaned off mechanical ventilation. Noninvasive positive-pressure ventilation (NPPV) has been shown to facilitate weaning in mechanically ventilated patients.
To assess the effect of NPPV on re-intubation rate and intensive care unit and/or hospital mortality in patients with postextubation respiratory failure.
We searched the MEDLINE, EMBASE, OVID, CINAHL, DARE, and CENTRAL databases for relevant studies published from 1980 to 2006, and included randomized controlled trials that evaluated the role of NPPV in patients with postextubation respiratory failure. Independently and in duplicate, two of us abstracted data from these trials. Differences in opinion were settled via consensus or after consultation with a third author.
Four studies met our inclusion criteria: two used NPPV in the setting of established postextubation respiratory failure, and two used NPPV in patients "at risk" for postextubation respiratory failure. NPPV, compared to the standard medical therapy, did not decrease the re-intubation rate (relative risk [RR] 1.03, 95% confidence interval [CI]0.84-1.25) or intensive care unit mortality (RR 1.14, 95% CI 0.43-3.0) in patients (n = 302) with postextubation respiratory failure. However, in patients (n = 259) who were defined to be at high risk for developing postextubation respiratory failure, NPPV decreased the re-intubation rate (RR 0.46, 95% CI 0.25-0.84) and intensive care unit mortality (RR 0.26, 95% CI 0.1-0.66), but not the hospital mortality (RR 0.71, 95% CI 0.42-1.20).
Current evidence suggests that NPPV should be used judiciously, if at all, in patients with postextubation respiratory failure, but it appears to be promising as a prophylaxis to prevent re-intubation in patients "at risk" for developing postextubation respiratory failure.
对于已撤离机械通气的患者,需要一种预防再次插管的干预措施。无创正压通气(NPPV)已被证明有助于机械通气患者的撤机。
评估NPPV对拔管后呼吸衰竭患者再次插管率以及重症监护病房和/或医院死亡率的影响。
我们检索了MEDLINE、EMBASE、OVID、CINAHL、DARE和CENTRAL数据库,查找1980年至2006年发表的相关研究,纳入评估NPPV在拔管后呼吸衰竭患者中作用的随机对照试验。我们两人独立且重复地从这些试验中提取数据。意见分歧通过协商一致或与第三位作者商议解决。
四项研究符合我们的纳入标准:两项在已确诊的拔管后呼吸衰竭患者中使用NPPV,两项在有拔管后呼吸衰竭“风险”的患者中使用NPPV。与标准药物治疗相比,NPPV并未降低拔管后呼吸衰竭患者(n = 302)的再次插管率(相对危险度[RR] 1.03,95%置信区间[CI] 0.84 - 1.25)或重症监护病房死亡率(RR 1.14,95% CI 0.43 - 3.0)。然而,在被定义为发生拔管后呼吸衰竭高风险的患者(n = 259)中,NPPV降低了再次插管率(RR 0.46,95% CI 0.25 - 0.84)和重症监护病房死亡率(RR 0.26,95% CI 0.1 - 0.66),但未降低医院死亡率(RR 0.71,95% CI 0.42 - 1.20)。
目前的证据表明,对于拔管后呼吸衰竭患者,若要使用NPPV应谨慎,不过对于有发生拔管后呼吸衰竭“风险”的患者,NPPV作为预防再次插管的措施似乎很有前景。