The Royal Women's Hospital, Melbourne, Victoria, Australia2Deakin University, Melbourne, Victoria, Australia.
The Royal Women's Hospital, Melbourne, Victoria, Australia3The University of Melbourne, Melbourne, Victoria, Australia.
JAMA Pediatr. 2017 Feb 1;171(2):165-174. doi: 10.1001/jamapediatrics.2016.3015.
Clinicians aim to extubate preterm infants as early as possible, to minimize the risks of mechanical ventilation. Extubation is often unsuccessful owing to lung disease or inadequate respiratory drive.
To conduct a systematic review and meta-analysis of interventions to improve rates of successful extubation in preterm infants.
Searches were undertaken in PubMed and The Cochrane Library.
The review was conducted using the methods of the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they were randomized clinical trials published in English, enrolled intubated preterm infants (born <37 weeks' gestation), and reported 1 or both of the primary outcomes.
One thousand three hundred seventy-nine titles were screened independently by 2 investigators to assess need for full-text review. Disagreements were resolved via consensus of all authors. Where no Cochrane Review existed for an intervention, or not all identified studies were included, a new pooled analysis was performed.
Primary outcomes were treatment failure or reintubation within 7 days of extubation.
Fifty studies were eligible for inclusion. Continuous positive airway pressure reduced extubation failure in comparison with head-box oxygen (risk ratio [RR], 0.59; 95% CI, 0.48-0.72; number needed to treat [NNT], 6; 95% CI, 3-9). Nasal intermittent positive pressure ventilation was superior to continuous positive airway pressure in preventing extubation failure (RR, 0.70; 95% CI, 0.60-0.81; NNT, 8; 95% CI, 5-13). High-flow nasal cannula therapy and continuous positive airway pressure had similar efficacy (RR, 1.11; 95% CI, 0.84-1.47). Methylxanthines reduced extubation failure (RR, 0.48; 95% CI, 0.32-0.71; NNT, 4; 95% CI, 2-7) compared with placebo or no treatment. Corticosteroids (RR, 0.18; 95% CI, 0.04-0.97; NNT, 12; 95% CI, 6-100) and chest physiotherapy (RR, 0.32; 95% CI, 0.13-0.82; NNT, 15; 95% CI, 7-50) both reduced extubation failure rates but were associated with significant adverse effects. Doxapram did not aid successful extubation (RR, 0.80; 95% CI, 0.22-2.97).
Preterm infants should be extubated to noninvasive respiratory support. Caffeine should be used routinely, while corticosteroids should be used judiciously, weighing up the competing risks of bronchopulmonary dysplasia and neurodevelopmental harm.
临床医生的目标是尽早为早产儿拔管，以最大程度降低机械通气的风险。由于肺部疾病或呼吸驱动不足，拔管往往不成功。
对改善早产儿拔管成功率的干预措施进行系统评价和荟萃分析。
在 PubMed 和 The Cochrane Library 中进行了检索。
该综述使用了 Cochrane 协作组织和系统评价和荟萃分析首选报告项目的方法进行。如果研究为随机临床试验、纳入经气管插管的早产儿（出生时 <37 周妊娠），并报告了 1 个或 2 个主要结局，则纳入研究。
2 名研究者独立筛选了 1379 个标题，以评估是否需要全文审查。分歧通过所有作者的共识解决。对于干预措施，如果没有 Cochrane 综述存在，或者并非所有确定的研究都被纳入，则进行新的汇总分析。
主要结局为拔管后 7 天内治疗失败或再插管。
50 项研究符合纳入标准。与头罩吸氧相比，持续气道正压通气降低了拔管失败率（风险比 [RR]，0.59；95%置信区间，0.48-0.72；需要治疗的人数 [NNT]，6；95%置信区间，3-9）。与持续气道正压通气相比，经鼻间歇正压通气更能预防拔管失败（RR，0.70；95%置信区间，0.60-0.81；NNT，8；95%置信区间，5-13）。高流量鼻导管治疗和持续气道正压通气的疗效相似（RR，1.11；95%置信区间，0.84-1.47）。与安慰剂或不治疗相比，甲基黄嘌呤降低了拔管失败率（RR，0.48；95%置信区间，0.32-0.71；NNT，4；95%置信区间，2-7）。皮质类固醇（RR，0.18；95%置信区间，0.04-0.97；NNT，12；95%置信区间，6-100）和胸部物理治疗（RR，0.32；95%置信区间，0.13-0.82；NNT，15；95%置信区间，7-50）均降低了拔管失败率，但均伴有显著的不良反应。多沙普仑并不能帮助成功拔管（RR，0.80；95%置信区间，0.22-2.97）。
早产儿应拔管至非侵入性呼吸支持。应常规使用咖啡因，而皮质类固醇应谨慎使用，权衡支气管肺发育不良和神经发育损害的竞争风险。
