对于对呼气末正压（PEEP）有临床客观氧合改善反应的急性呼吸窘迫综合征（ARDS）患者，较高的PEEP可改善预后：一项系统评价和荟萃分析。

Higher PEEP improves outcomes in ARDS patients with clinically objective positive oxygenation response to PEEP: a systematic review and meta-analysis.

作者信息

Guo Lanqi, Xie Jianfeng, Huang Yingzi, Pan Chun, Yang Yi, Qiu Haibo, Liu Ling

机构信息

Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China.

出版信息

BMC Anesthesiol. 2018 Nov 17;18(1):172. doi: 10.1186/s12871-018-0631-4.

BACKGROUND

Mortality in patients with acute respiratory distress syndrome (ARDS) remains high. These patients require mechanical ventilation strategies that include high positive end-expiratory pressure (PEEP). It remains controversial whether high PEEP can improve outcomes for ARDS patients, especially patients who show improvement in oxygenation in response to PEEP. In this meta-analysis, we aimed to evaluate the effects of high PEEP on ARDS patients.

METHODS

We electronically searched randomized controlled trials (RCTs) reported in the MEDLINE, CENTRAL, EMBASE, CINAHL and Web of Science databases from January 1990 to December 2017. Meta-analyses of the effects of PEEP on survival in adults with ARDS were conducted using the methods recommended by the Cochrane Collaboration.

RESULTS

A total of 3612 patients from nine randomized controlled trials (RCTs) were included. There were 1794 and 1818 patients in the high and low PEEP groups, respectively. Hospital mortality showed no significant difference between the high and low PEEP groups (RR = 0.92; 95% CI, 0.79 to 1.07; P = 0.26). Similar results were found for 28-d mortality (RR = 0.88; 95% CI, 0.72 to 1.07; P = 0.19) and ICU mortality (RR = 0.83; 95% CI, 0.65 to 1.07; P = 0.15). The risk of clinically objectified barotrauma was not significantly different between the high and low PEEP groups (RR = 1.24; 95% CI, 0.74 to 2.09, P = 0.41). In the subgroup of ARDS patients who responded to increased PEEP by improved oxygenation (from 6 RCTs), high PEEP significantly reduced hospital mortality (RR = 0.83; 95% CI 0.69 to 0.98; P = 0.03), ICU mortality (RR = 0.74; 95% CI, 0.56 to 0.98; P = 0.04),but the 28-d mortality was not decreased(RR = 0.83; 95% CI, 0.67 to 1.01; P = 0.07). For ARDS patients in the low PEEP group who received a PEEP level lower than 10 cmHO (from 6 RCTs), ICU mortality was lower in the high PEEP group than the low PEEP group (RR = 0.65; 95% CI, 0.45 to 0.94; P = 0.02).

CONCLUSIONS

For ARDS patients who responded to increased PEEP by improved oxygenation, high PEEP could reduce hospital mortality, ICU mortality and 28-d mortality. High PEEP does not increase the risk of clinically objectified barotrauma.

背景

急性呼吸窘迫综合征（ARDS）患者的死亡率仍然很高。这些患者需要包括高呼气末正压（PEEP）在内的机械通气策略。高PEEP是否能改善ARDS患者的预后，尤其是对PEEP有氧合改善反应的患者，仍存在争议。在这项荟萃分析中，我们旨在评估高PEEP对ARDS患者的影响。

方法

我们通过电子检索1990年1月至2017年12月期间MEDLINE、CENTRAL、EMBASE、CINAHL和科学引文索引数据库中报告的随机对照试验（RCT）。使用Cochrane协作网推荐的方法对PEEP对成人ARDS患者生存的影响进行荟萃分析。

结果

共纳入来自9项随机对照试验（RCT）的3612例患者。高PEEP组和低PEEP组分别有1794例和1818例患者。高PEEP组和低PEEP组的医院死亡率无显著差异（RR = 0.92；95%CI，0.79至1.07；P = 0.26）。28天死亡率（RR = 0.88；95%CI，0.72至1.07；P = 0.19）和ICU死亡率（RR = 0.83；95%CI，0.65至1.07；P = 0.15）也有类似结果。高PEEP组和低PEEP组临床确诊的气压伤风险无显著差异（RR = 1.24；95%CI，0.74至2.09，P = 0.41）。在对增加PEEP有氧合改善反应的ARDS患者亚组（来自6项RCT）中，高PEEP显著降低了医院死亡率（RR = 0.83；95%CI 0.69至0.98；P = 0.03）、ICU死亡率（RR = 0.74；95%CI，0.56至0.98；P = 0.04），但28天死亡率未降低（RR = 0.83；95%CI，0.67至1.01；P = 0.07）。对于低PEEP组中接受低于10 cmH₂O的PEEP水平的ARDS患者（来自6项RCT），高PEEP组的ICU死亡率低于低PEEP组（RR = 0.65；95%CI，0.45至0.94；P = 0.02）。