Ellekjaer K L, Meyhoff T S, Møller M H
Department of Intensive Care 4131, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
Acta Anaesthesiol Scand. 2017 Nov;61(10):1240-1252. doi: 10.1111/aas.13000.
We aimed to assess patient-important benefits and harms of therapeutic bronchoscopy vs. standard of care (no bronchoscopy) in critically ill patients with acute respiratory failure (ARF).
We conducted a systematic review with meta-analysis and trial sequential analysis (TSA) according to the Cochrane Handbook and GRADE methodology, including a predefined protocol (PROSPERO no. CRD42016046235). We included randomized clinical trials (RCTs) comparing therapeutic bronchoscopy to standard of care in critically ill patients with ARF. Two reviewers independently assessed trials for inclusion, extracted data and assessed risk of bias. Risk ratios (RR) with 95% confidence intervals (CI) were estimated by conventional meta-analysis. The risk of random errors was assessed by TSA. Exclusively patient-important outcomes were evaluated.
We included five trials (n = 212); all were judged as having high risk of bias. There was no difference in all-cause mortality between therapeutic bronchoscopy and standard of care (TSA adjusted RR 0.39; 95% CI 0.14 to 1.07; I 0%), and only 3% of the required information size had been accrued. There was no difference in ICU length of stay. A shorter duration of mechanical ventilation was suggested by conventional meta-analysis, however TSA highlighted that only 42% of the required information size had been accrued, indicating high risk of random errors. No trials reported data on adverse events, hospital length of stay, quality of life or performance status.
The quantity and quality of evidence supporting therapeutic bronchoscopy in critically ill patients with ARF is very low with no firm evidence for benefit or harm.
我们旨在评估治疗性支气管镜检查与标准治疗（不进行支气管镜检查）对急性呼吸衰竭（ARF）危重症患者的重要益处和危害。
我们根据Cochrane手册和GRADE方法进行了系统评价、荟萃分析和试验序贯分析（TSA），包括一个预先定义的方案（PROSPERO编号：CRD42016046235）。我们纳入了比较治疗性支气管镜检查与ARF危重症患者标准治疗的随机临床试验（RCT）。两名研究者独立评估试验是否纳入、提取数据并评估偏倚风险。通过传统荟萃分析估计风险比（RR）及95%置信区间（CI）。通过TSA评估随机误差风险。仅评估对患者重要的结局。
我们纳入了五项试验（n = 212）；所有试验均被判定为具有高偏倚风险。治疗性支气管镜检查与标准治疗在全因死亡率方面无差异（TSA校正RR 0.39；95%CI 0.14至1.07；I² 0%），且仅积累了所需信息量的3%。在重症监护病房住院时间方面无差异。传统荟萃分析提示机械通气时间较短，然而TSA强调仅积累了所需信息量的42%，表明随机误差风险高。没有试验报告不良事件、住院时间、生活质量或功能状态的数据。
支持对ARF危重症患者进行治疗性支气管镜检查的证据数量和质量非常低，没有确凿证据表明其有益或有害。
