Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada.
PLoS One. 2011 Jan 28;6(1):e14623. doi: 10.1371/journal.pone.0014623.
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are life threatening clinical conditions seen in critically ill patients with diverse underlying illnesses. Lung injury may be perpetuated by ventilation strategies that do not limit lung volumes and airway pressures. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing pressure and volume-limited (PVL) ventilation strategies with more traditional mechanical ventilation in adults with ALI and ARDS.
We searched Medline, EMBASE, HEALTHSTAR and CENTRAL, related articles on PubMed™, conference proceedings and bibliographies of identified articles for randomized trials comparing PVL ventilation with traditional approaches to ventilation in critically ill adults with ALI and ARDS. Two reviewers independently selected trials, assessed trial quality, and abstracted data. We identified ten trials (n = 1,749) meeting study inclusion criteria. Tidal volumes achieved in control groups were at the lower end of the traditional range of 10-15 mL/kg. We found a clinically important but borderline statistically significant reduction in hospital mortality with PVL [relative risk (RR) 0.84; 95% CI 0.70, 1.00; p = 0.05]. This reduction in risk was attenuated (RR 0.90; 95% CI 0.74, 1.09, p = 0.27) in a sensitivity analysis which excluded 2 trials that combined PVL with open-lung strategies and stopped early for benefit. We found no effect of PVL on barotrauma; however, use of paralytic agents increased significantly with PVL (RR 1.37; 95% CI, 1.04, 1.82; p = 0.03).
This systematic review suggests that PVL strategies for mechanical ventilation in ALI and ARDS reduce mortality and are associated with increased use of paralytic agents.
急性肺损伤（ALI）和急性呼吸窘迫综合征（ARDS）是危及生命的临床病症，见于患有各种基础疾病的重症患者。通气策略可能会使肺损伤持续存在，这些策略不能限制肺容量和气道压力。我们对比较压力和容量限制（PVL）通气策略与传统机械通气治疗 ALI 和 ARDS 成人患者的随机对照试验（RCT）进行了系统评价和荟萃分析。
我们检索了 Medline、EMBASE、HEALTHSTAR 和 CENTRAL、PubMed™ 上的相关文章、会议记录和已确定文章的参考文献，以查找比较 PVL 通气与传统通气方法治疗 ALI 和 ARDS 重症成人患者的 RCT。两位审查员独立选择试验、评估试验质量并提取数据。我们确定了 10 项符合研究纳入标准的试验（n=1749）。对照组中实现的潮气量处于传统范围（10-15mL/kg）的下限。我们发现，与传统通气方法相比，PVL 可显著降低医院死亡率（相对风险[RR]0.84；95%置信区间[CI]0.70，1.00；p=0.05）。但在敏感性分析中，该风险降低程度减弱（RR 0.90；95% CI 0.74，1.09，p=0.27），该分析排除了 2 项将 PVL 与开肺策略结合并因获益而提前停止的试验。我们未发现 PVL 对气压伤有影响；但是，PVL 可显著增加使用麻痹剂的频率（RR 1.37；95% CI，1.04，1.82；p=0.03）。
本系统评价表明，ALI 和 ARDS 机械通气的 PVL 策略可降低死亡率，并与麻痹剂使用率增加相关。
