Department of Pulmonary Medicine, Center of Snoring and Sleep Apnea Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China.
Chin Med J (Engl). 2013 Apr;126(7):1337-43.
Noninvasive positive pressure ventilation (NIPPV) has been proposed to shorten the duration of mechanical ventilation in intubated patients, especially those who fail initial weaning from invasive mechanical ventilation (IMV). However, there are also some discrepancies in terms of weaning success or failure, incidence of re-intubation, complications observed during study and patient outcomes. The primary objective of this update was to specifically investigate the role of NIPPV on facilitating weaning and avoiding re-intubation in patients intubated for different etiologies of acute respiratory failure, by comparing with conventional invasive weaning approach.
We searched randomized controlled trials (RCTs) comparing noninvasive weaning of early extubation and immediate application of NIPPV with invasive weaning in intubated patients from PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Knowledge and Springerlink databases. Records from conference proceedings and reference lists of relevant studies were also identified.
A total of 11 RCTs with 623 patients were available for the present analysis. Compared with IMV, NIPPV significantly increased weaning success rates (odds ratio (OR): 2.50, 95% confidence interval (CI): 1.46 - 4.30, P = 0.0009), decreased mortality (OR: 0.39, 95%CI: 0.20 - 0.75, P = 0.005), and reduced the incidence of ventilator associated pneumonia (VAP) (OR: 0.17, 95%CI: 0.08 - 0.37, P < 0.00001) and complications (OR: 0.22, 95%CI: 0.07 - 0.72, P = 0.01). However, effect of NIPPV on re-intubation did not reach statistical difference (OR: 0.61, 95%CI: 0.33 - 1.11, P = 0.11).
Early extubation and immediate application of NIPPV is superior to conventional invasive weaning approach in increasing weaning success rates, decreasing the risk of mortality and reducing the incidence of VAP and complications, in patients who need weaning from IMV. However, it should be applied with caution, as there is insufficient beneficial evidence to definitely recommend it in terms of avoiding re-intubation.
无创正压通气（NIPPV）已被提出用于缩短插管患者机械通气的持续时间，尤其是那些最初从有创机械通气（IMV）脱机失败的患者。然而，在脱机成功或失败、再次插管发生率、研究期间观察到的并发症和患者结局方面，也存在一些差异。本次更新的主要目的是通过与常规有创脱机方法比较，专门研究 NIPPV 在因不同病因导致急性呼吸衰竭而插管的患者中促进脱机和避免再次插管的作用。
我们从 PubMed、Embase、Cochrane 中央对照试验注册库、Web of Knowledge 和 Springerlink 数据库中检索了比较早期拔管和立即应用 NIPPV 与有创脱机的无创脱机的随机对照试验（RCT）。还确定了会议记录和相关研究参考文献列表中的记录。
共有 11 项 RCT 纳入了 623 例患者，可用于本分析。与 IMV 相比，NIPPV 显著增加了脱机成功率（优势比（OR）：2.50，95%置信区间（CI）：1.46-4.30，P = 0.0009），降低了死亡率（OR：0.39，95%CI：0.20-0.75，P = 0.005），并降低了呼吸机相关性肺炎（VAP）（OR：0.17，95%CI：0.08-0.37，P < 0.00001）和并发症（OR：0.22，95%CI：0.07-0.72，P = 0.01）的发生率。然而，NIPPV 对再次插管的影响没有达到统计学差异（OR：0.61，95%CI：0.33-1.11，P = 0.11）。
在需要从 IMV 脱机的患者中，早期拔管和立即应用 NIPPV 优于常规有创脱机方法，可提高脱机成功率、降低死亡率风险、降低 VAP 和并发症发生率。然而，由于没有足够的有益证据确定其在避免再次插管方面的益处，因此应谨慎应用。
