Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.
Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
Crit Care Med. 2018 Aug;46(8):1209-1216. doi: 10.1097/CCM.0000000000003082.
To assess the effectiveness of noninvasive ventilation in patients with acute respiratory failure and do-not-intubate or comfort-measures-only orders.
MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science from inception to January 1, 2017.
Studies of all design types that enrolled patients in the ICU or hospital ward who received noninvasive ventilation and had preset do-not-intubate or comfort-measures-only orders.
Data abstraction followed Meta-analysis of Observational Studies in Epidemiology guidelines. Data quality was assessed using a modified Newcastle-Ottawa Scale.
Twenty-seven studies evaluating 2,020 patients with do-not-intubate orders and three studies evaluating 200 patients with comfort-measures-only orders were included. In patients with do-not-intubate orders, the pooled survival was 56% (95% CI, 49-64%) at hospital discharge and 32% (95% CI, 21-45%) at 1 year. Hospital survival was 68% for chronic obstructive pulmonary disease, 68% for pulmonary edema, 41% for pneumonia, and 37% for patients with malignancy. Survival was comparable for patients treated in a hospital ward versus an ICU. Quality of life of survivors was not reduced compared with baseline, although few studies evaluated this. No studies evaluated quality of dying in nonsurvivors. In patients with comfort-measures-only orders, a single study showed that noninvasive ventilation was associated with mild reductions in dyspnea and opioid requirements.
A large proportion of patients with do-not-intubate orders who received noninvasive ventilation survived to hospital discharge and at 1 year, with limited data showing no decrease in quality of life in survivors. Provision of noninvasive ventilation in a well-equipped hospital ward may be a viable alternative to the ICU for selected patients. Crucial questions regarding quality of life in survivors, quality of death in nonsurvivors, and the impact of noninvasive ventilation in patients with comfort-measures-only orders remain largely unanswered.
评估无创通气在有“不插管”或“仅舒适护理”医嘱的急性呼吸衰竭患者中的疗效。
从建库至 2017 年 1 月 1 日，MEDLINE、EMBASE、CINAHL、Scopus 和 Web of Science。
所有设计类型的研究，均纳入在 ICU 或医院病房接受无创通气且有预设“不插管”或“仅舒适护理”医嘱的患者。
数据提取遵循观察性研究的荟萃分析流行病学指南。使用改良的 Newcastle-Ottawa 量表评估数据质量。
共纳入 27 项评估“不插管”医嘱患者 2020 例的研究和 3 项评估“仅舒适护理”医嘱患者 200 例的研究。“不插管”医嘱患者的出院时存活率为 56%（95%CI，49%-64%），1 年存活率为 32%（95%CI，21%-45%）。慢性阻塞性肺疾病患者的住院存活率为 68%，肺水肿患者为 68%，肺炎患者为 41%，恶性肿瘤患者为 37%。在 ICU 和医院病房接受治疗的患者存活率相当。与基线相比，存活者的生活质量并未降低，但很少有研究对此进行评估。没有研究评估非存活者的临终质量。在有“仅舒适护理”医嘱的患者中，仅有一项研究表明，无创通气可使呼吸困难和阿片类药物需求轻度减轻。
接受无创通气的“不插管”医嘱患者中，很大一部分比例可存活至出院和 1 年，只有有限的数据表明存活者的生活质量没有下降。为有选择的患者在设备齐全的医院病房中提供无创通气可能是 ICU 的可行替代方案。幸存者的生活质量、非幸存者的死亡质量以及“仅舒适护理”医嘱患者中无创通气的影响等关键问题仍基本未得到解答。
