预防肺部并发症的术中通气策略的Meta分析：仅低潮气量就足以保护健康肺脏吗？

A Meta-analysis of Intraoperative Ventilation Strategies to Prevent Pulmonary Complications: Is Low Tidal Volume Alone Sufficient to Protect Healthy Lungs?

作者信息

Yang Dongjie, Grant Michael C, Stone Alexander, Wu Christopher L, Wick Elizabeth C

机构信息

*Department of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China †Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Institutions, Baltimore, MD ‡Department of Surgery, The Johns Hopkins Institutions, Baltimore, MD.

出版信息

Ann Surg. 2016 May;263(5):881-7. doi: 10.1097/SLA.0000000000001443.

DOI:10.1097/SLA.0000000000001443

PMID:26720429

Abstract

BACKGROUND

The clinical benefits of intraoperative low tidal volume (LTV) mechanical ventilation with concomittent positive end expiratory pressure (PEEP) and intermittent recruitment maneuvers-termed "protective lung ventilation" (PLV)-have not been investigated systematically in otherwise healthy patients undergoing general anesthesia.

METHODS

Our group performed a meta-analysis of 16 studies (n = 1054) comparing LTV (n = 521) with conventional lung ventilation (n = 533) for associated postoperative incidence of atelectasis, lung infection, acute lung injury (ALI), and length of hospital stay. A secondary analysis of 3 studies comparing PLV (n = 248) with conventional lung ventilation (n = 247) was performed.

RESULTS

Although intraoperative LTV ventilation was associated with a decreased incidence of postoperative lung infection (odds ratio [OR] = 0.33; 95% confidence interval [CI], 0.16-0.68; P = 0.003) compared with a conventional strategy, no difference was noted between groups in incidence of postoperative ALI (OR = 0.38; 95% CI, 0.10-1.52; P = 0.17) or atelectasis (OR = 0.86; 95% CI, 0.26-2.81; P = 0.80). Analysis of trials involving protective ventilation (LTV + PEEP + recruitment maneuvers) showed a statistically significant reduction in incidence of postoperative lung infection (OR = 0.21; 95% CI, 0.09-0.50; P = 0.0003), atelectasis (OR = 0.36; 95% CI, 0.20-0.64; P = 0.006), and ALI (OR = 0.15; 95% CI, 0.04-0.61; P = 0.008) and length of hospital stay (Mean Difference = -2.08; 95% CI, -3.95 to -0.21; P = 0.03) compared with conventional ventilation.

CONCLUSIONS

Intraoperative LTV ventilation in conjunction with PEEP and intermittent recruitment maneuvers is associated with significantly improved clinical pulmonary outcomes and reduction in length of hospital stay in otherwise healthy patients undergoing general surgery. Providers should consider application of all the 3 elements for a comprehensive protective ventilation strategy.

摘要

背景

在接受全身麻醉的健康患者中，尚未对术中低潮气量（LTV）机械通气联合呼气末正压（PEEP）和间歇性肺复张手法（即“肺保护性通气”[PLV]）的临床益处进行系统研究。

方法

我们的研究小组对16项研究（n = 1054）进行了荟萃分析，比较了LTV（n = 521）与传统肺通气（n = 533）在术后肺不张、肺部感染、急性肺损伤（ALI）发生率及住院时间方面的差异。还对3项比较PLV（n = 248）与传统肺通气（n = 247）的研究进行了二次分析。

结果

尽管与传统策略相比，术中LTV通气与术后肺部感染发生率降低相关（优势比[OR]=0.33；95%置信区间[CI]，0.16 - 0.68；P = 0.003），但两组在术后ALI发生率（OR = 0.38；95% CI，0.10 - 1.52；P = 0.17）或肺不张发生率（OR = 0.86；95% CI，0.26 - 2.81；P = 0.80）方面无差异。对涉及保护性通气（LTV + PEEP + 肺复张手法）的试验分析表明，与传统通气相比，术后肺部感染发生率（OR = 0.21；95% CI，0.09 - 0.50；P = 0.0003）、肺不张发生率（OR = 0.36；95% CI，0.20 - 0.64；P = 0.006）、ALI发生率（OR = 0.15；95% CI，0.04 - 0.61；P = 0.008）及住院时间（平均差=-2.08；95% CI，-3.95至-0.21；P = 0.03）均有显著降低。