1 Division of Respirology, Department of Medicine, and.
2 Keenan Centre for Biomedical Research, St. Michael's Hospital, Toronto, Ontario, Canada.
Ann Am Thorac Soc. 2018 Jun;15(6):735-744. doi: 10.1513/AnnalsATS.201712-961OC.
Respiratory muscle weakness is common in critically ill patients; the role of targeted inspiratory muscle training (IMT) in intensive care unit rehabilitation strategies remains poorly defined.
The primary objective of the present study was to describe the range and tolerability of published methods for IMT. The secondary objectives were to determine whether IMT improves respiratory muscle strength and clinical outcomes in critically ill patients.
We conducted a systematic review to identify randomized and nonrandomized studies of physical rehabilitation interventions intended to strengthen the respiratory muscles in critically ill adults. We searched the MEDLINE, Embase, HealthSTAR, CINAHL, and CENTRAL databases (inception to September Week 3, 2017) and conference proceedings (2012 to 2017). Data were independently extracted by two authors and collected on a standardized report form.
A total of 28 studies (N = 1,185 patients) were included. IMT was initiated during early mechanical ventilation (8 studies), after patients proved difficult to wean (14 studies), or after extubation (3 studies), and 3 other studies did not report exact timing. Threshold loading was the most common technique; 13 studies employed strength training regimens, 11 studies employed endurance training regimens, and 4 could not be classified. IMT was feasible, and there were few adverse events during IMT sessions (nine studies; median, 0%; interquartile range, 0-0%). In randomized trials (n = 20), IMT improved maximal inspiratory pressure compared with control (15 trials; mean increase, 6 cm HO; 95% confidence interval [CI], 5-8 cm HO; pooled relative ratio of means, 1.19; 95% CI, 1.14-1.25) and maximal expiratory pressure (4 trials; mean increase, 9 cm HO; 95% CI, 5-14 cm HO). IMT was associated with a shorter duration of ventilation (nine trials; mean difference, 4.1 d; 95% CI, 0.8-7.4 d) and a shorter duration of weaning (eight trials; mean difference, 2.3 d; 95% CI, 0.7-4.0 d), but confidence in these pooled estimates was low owing to methodological limitations, including substantial statistical and methodological heterogeneity.
Most studies of IMT in critically ill patients have employed inspiratory threshold loading. IMT is feasible and well tolerated in critically ill patients and improves both inspiratory and expiratory muscle strength. The impact of IMT on clinical outcomes requires future confirmation.
呼吸肌无力在危重症患者中很常见；针对吸气肌训练（IMT）在重症监护病房康复策略中的作用仍未得到明确界定。
本研究的主要目的是描述已发表的 IMT 方法的范围和可接受性。次要目的是确定 IMT 是否能改善危重症患者的呼吸肌力量和临床结局。
我们进行了一项系统评价，以确定旨在增强危重症成人呼吸肌力量的物理康复干预措施的随机和非随机研究。我们检索了 MEDLINE、Embase、HealthSTAR、CINAHL 和 CENTRAL 数据库（从创建到 2017 年 9 月第 3 周）和会议记录（2012 年至 2017 年）。两名作者独立提取数据，并在标准化报告表上进行收集。
共纳入 28 项研究（N=1185 例患者）。IMT 开始于早期机械通气时（8 项研究）、患者撤机困难时（14 项研究）或拔管后（3 项研究），另外 3 项研究未报告确切的时机。阈负荷是最常用的技术；13 项研究采用力量训练方案，11 项研究采用耐力训练方案，4 项研究无法分类。IMT 是可行的，在 IMT 过程中很少发生不良事件（9 项研究；中位数，0%；四分位间距，0-0%）。在随机试验（n=20）中，与对照组相比，IMT 可改善最大吸气压力（15 项试验；平均增加 6 cm H2O；95%置信区间[CI]，5-8 cm H2O；平均比值，1.19；95% CI，1.14-1.25）和最大呼气压力（4 项试验；平均增加 9 cm H2O；95% CI，5-14 cm H2O）。IMT 与通气时间缩短（9 项试验；平均差异，4.1 d；95% CI，0.8-7.4 d）和撤机时间缩短相关（8 项试验；平均差异，2.3 d；95% CI，0.7-4.0 d），但由于方法学限制，包括统计学和方法学上的显著异质性，这些汇总估计的可信度较低。
大多数关于危重症患者 IMT 的研究都采用了吸气阈负荷。IMT 在危重症患者中是可行的且耐受性良好，可改善吸气和呼气肌力量。IMT 对临床结局的影响需要进一步证实。
