Chen Yu-Chih
Department of Nursing, Taipei Veterans General Hospital, School of Nursing, Taipei Medical University and National Taipei College of Nursing, Taipei, Taiwan, R.O.C.
J Chin Med Assoc. 2009 Apr;72(4):171-8. doi: 10.1016/S1726-4901(09)70049-8.
Ventilator-associated pneumonia (VAP) is a common cause of morbidity in critically ill patients. Appropriate enteral feeding is the most important factor associated with the prevention of VAP. However, the standardization of enteral feeding methods needs clarification. The purpose of this systematic review was to synthesize the factors associated with enteral feeding in order to prevent VAP and to describe the characteristics of these factors. A comprehensive search was undertaken involving all major databases from their inception to September 2008 using medical subject heading terms associated with enteral feeding in relation to VAP. The overall reference list of identified studies was audited, and eligible studies included randomized controlled trials, controlled before-and-after (pre-post) studies and meta-analyses. To generate the characteristics of the factors associated with VAP, the reported components of these trials were pinpointed and categorized. A total of 14 papers were found that had investigated the factors linking enteral feeding and VAP. For these, 11 were randomized controlled trials, 1 was a meta-analysis and 2 were case-controlled analyses. Twelve of these 14 studies were conducted at a single institute and 2 were conducted at multiple institutes. The sample sizes varied from 10 to 2,528 subjects. Three major issues were identified based on the purpose of study interventions, and these were the effects of feeding method (continuous vs. intermittent), feeding site on aspiration (gastric vs. small bowel), and the timing of enteral feeding (early vs. late). The evidence suggests that a correct choice of enteral feeding method can effectively reduce complications due to aspiration. Furthermore, intermittent enteral feeding and with a small residual volume feed can reduce gastroesophageal reflux, and increased total intake volume and early feeding can reduce ICU mortality. Nonetheless, the effects of these choices on preventing VAP still need further evaluation. A set of clinical guidelines based on these evidence-based findings with respect to enteral feeding is required, particularly one that covers all aspects of the enteral feeding process.
呼吸机相关性肺炎（VAP）是危重症患者发病的常见原因。适当的肠内营养是预防VAP的最重要因素。然而，肠内营养方法的标准化仍需明确。本系统评价的目的是综合与肠内营养相关的因素，以预防VAP并描述这些因素的特征。我们进行了全面检索，使用与VAP相关的肠内营养医学主题词，涵盖所有主要数据库从建库至2008年9月的内容。对已识别研究的全部参考文献列表进行审核，符合条件的研究包括随机对照试验、前后对照（干预前后）研究和荟萃分析。为了得出与VAP相关因素的特征，明确并分类这些试验报告的组成部分。共发现14篇研究肠内营养与VAP相关因素的论文。其中，11篇为随机对照试验，1篇为荟萃分析，2篇为病例对照分析。这14项研究中有12项在单一机构进行，2项在多个机构进行。样本量从10至2528名受试者不等。基于研究干预目的确定了三个主要问题，即喂养方式（持续喂养与间歇喂养）、喂养部位对误吸的影响（胃喂养与小肠喂养）以及肠内营养的时机（早期喂养与晚期喂养）。有证据表明，正确选择肠内营养方法可有效减少误吸引起的并发症。此外，间歇肠内营养和小残留量喂养可减少胃食管反流，增加总摄入量和早期喂养可降低重症监护病房（ICU）死亡率。尽管如此，这些选择对预防VAP的效果仍需进一步评估。需要一套基于这些循证结果的肠内营养临床指南，尤其是涵盖肠内营养过程各个方面的指南。
