手术中保护性通气与传统通气的比较：系统评价和个体患者数据荟萃分析。
Protective versus Conventional Ventilation for Surgery: A Systematic Review and Individual Patient Data Meta-analysis.
作者信息
Serpa Neto Ary, Hemmes Sabrine N T, Barbas Carmen S V, Beiderlinden Martin, Biehl Michelle, Binnekade Jan M, Canet Jaume, Fernandez-Bustamante Ana, Futier Emmanuel, Gajic Ognjen, Hedenstierna Göran, Hollmann Markus W, Jaber Samir, Kozian Alf, Licker Marc, Lin Wen-Qian, Maslow Andrew D, Memtsoudis Stavros G, Reis Miranda Dinis, Moine Pierre, Ng Thomas, Paparella Domenico, Putensen Christian, Ranieri Marco, Scavonetto Federica, Schilling Thomas, Schmid Werner, Selmo Gabriele, Severgnini Paolo, Sprung Juraj, Sundar Sugantha, Talmor Daniel, Treschan Tanja, Unzueta Carmen, Weingarten Toby N, Wolthuis Esther K, Wrigge Hermann, Gama de Abreu Marcelo, Pelosi Paolo, Schultz Marcus J
机构信息
From the Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands (A.S.N., S.N.T.H., J.M.B., M.W.H., E.K.W., M.J.S.); Department of Pneumology, Heart Institute (INCOR), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil (A.S.N., C.S.V.B.); Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil (A.S.N., C.S.V.B.); Department of Anaesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany (M. Beiderlinden, T.T.); Department of Anaesthesiology, Marienhospital Osnabrück, Osnabrück, Germany (M. Beiderlinden); Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota (M. Biehl, O.G., J.S.); Department of Anesthesiology, Hospital Universitar I Germans Trias I Pujol, Barcelona, Spain (J.C.); Department of Anesthesiology, University of Colorado, Aurora, Colorado (A.F.-B., P.M.); Department of Anesthesiology and Critical Care Medicine, Estaing University Hospital, Clermont-Ferrand, France (E.F.); Department of Medical Sciences, Section of Clinical Physiology, University Hospital, Uppsala, Sweden (G.H.); Department of Critical Care Medicine and Anesthesiology (SAR B), Saint Eloi University Hospital, Montpellier, France (S.J.); Department of Anesthesiology and Intensive Care Medicine, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany (A.K., T.S.); Department of Anaesthesiology, Pharmacology and Intensive Care, Faculty of Medicine, University Hospital of Geneva, Geneva, Switzerland (M.L.); State Key Laboratory of Oncology of South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, People's Republic of China (W.-Q.L.); Department of Anesthesiology, The Warren Alpert School of Brown University, Providence, Rhode Island (A.D.M.); Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York (S.G.M.); Department of Intensive Ca
出版信息
Anesthesiology. 2015 Jul;123(1):66-78. doi: 10.1097/ALN.0000000000000706.
BACKGROUND
Recent studies show that intraoperative mechanical ventilation using low tidal volumes (VT) can prevent postoperative pulmonary complications (PPCs). The aim of this individual patient data meta-analysis is to evaluate the individual associations between VT size and positive end-expiratory pressure (PEEP) level and occurrence of PPC.
METHODS
Randomized controlled trials comparing protective ventilation (low VT with or without high levels of PEEP) and conventional ventilation (high VT with low PEEP) in patients undergoing general surgery. The primary outcome was development of PPC. Predefined prognostic factors were tested using multivariate logistic regression.
RESULTS
Fifteen randomized controlled trials were included (2,127 patients). There were 97 cases of PPC in 1,118 patients (8.7%) assigned to protective ventilation and 148 cases in 1,009 patients (14.7%) assigned to conventional ventilation (adjusted relative risk, 0.64; 95% CI, 0.46 to 0.88; P < 0.01). There were 85 cases of PPC in 957 patients (8.9%) assigned to ventilation with low VT and high PEEP levels and 63 cases in 525 patients (12%) assigned to ventilation with low VT and low PEEP levels (adjusted relative risk, 0.93; 95% CI, 0.64 to 1.37; P = 0.72). A dose-response relationship was found between the appearance of PPC and VT size (R2 = 0.39) but not between the appearance of PPC and PEEP level (R2 = 0.08).
CONCLUSIONS
These data support the beneficial effects of ventilation with use of low VT in patients undergoing surgery. Further trials are necessary to define the role of intraoperative higher PEEP to prevent PPC during nonopen abdominal surgery.
背景
近期研究表明，术中采用低潮气量（VT）进行机械通气可预防术后肺部并发症（PPC）。本个体患者数据荟萃分析的目的是评估VT大小和呼气末正压（PEEP）水平与PPC发生之间的个体关联。
方法
比较普通外科手术患者中保护性通气（低潮气量伴或不伴高水平PEEP）和传统通气（高潮气量伴低PEEP）的随机对照试验。主要结局是PPC的发生。使用多因素逻辑回归对预定义的预后因素进行检验。
结果
纳入15项随机对照试验（2127例患者）。分配至保护性通气组的1118例患者中有97例发生PPC（8.7%），分配至传统通气组的1009例患者中有148例发生PPC（14.7%）（校正相对风险，0.64；95%可信区间，0.46至0.88；P<0.01）。分配至低潮气量伴高水平PEEP通气组的957例患者中有85例发生PPC（8.9%），分配至低潮气量伴低水平PEEP通气组的525例患者中有63例发生PPC（12%）（校正相对风险，0.93；95%可信区间，0.64至1.37；P = 0.72）。发现PPC的出现与VT大小之间存在剂量反应关系（R2 = 0.39），但与PEEP水平之间不存在剂量反应关系（R2 = 0.08）。
结论
这些数据支持在手术患者中使用低潮气量通气的有益效果。有必要进行进一步试验以确定术中较高PEEP在非开放性腹部手术中预防PPC的作用。
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