低氧性呼吸衰竭和 ARDS 的规范化管理：系统评价和荟萃分析。
Standardized Management for Hypoxemic Respiratory Failure and ARDS: Systematic Review and Meta-analysis.
机构信息
Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.
Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
出版信息
Chest. 2020 Dec;158(6):2358-2369. doi: 10.1016/j.chest.2020.05.611. Epub 2020 Jul 3.
BACKGROUND
Treatment of hypoxemic respiratory failure (HRF) and ARDS is complex. Standardized management of HRF and ARDS may improve adherence to evidence-informed practice and improve outcomes.
RESEARCH QUESTION
What is the effect of standardized treatment compared with usual care on survival of patients with HRF and ARDS?
STUDY DESIGN AND METHODS
MEDLINE, EMBASE, Cochrane, CINAHL, Scopus, and Web-of-Science were searched (inception to 2018). Included studies were randomized clinical trials or quasi-experimental studies that examined the effect of standardized treatment (care-protocol, care-pathway, or bundle) compared with usual treatment among mechanically ventilated adult patients admitted to an ICU with HRF or ARDS. Study characteristics, pathway components, and patient outcomes were abstracted independently by two reviewers.
RESULTS
From 15,932 unique citations, 14 studies were included in the systematic review (three randomized clinical trials and 11 quasi-experimental studies). Twelve studies (including 5,767 patients) were included in the meta-analysis. Standardized management of HRF was associated with a 23% relative reduction in mortality (relative risk, 0.77; 95% CI, 0.65-0.91; I, 70%; P = .002). In studies targeting patients with ARDS (n = 8), a 21% pooled mortality reduction was observed (relative risk, 0.79; 95% CI, 0.71-0.88; I, 3.1%). Standardized management was associated with increased 28-day ventilator-free days (weighted mean difference, 3.48 days; 95% CI, 2.43-4.54 days; P < .001). Standardized management was also associated with a reduction in tidal volume (weighted mean difference, -1.80 mL/kg predicted body weight; 95% CI, -2.80 to -0.80 mL/kg predicted body weight; P < .001). Meta-regression demonstrated that the reduction in mortality was associated with provision of lower tidal volume (P = .045).
INTERPRETATION
When compared with usual treatment, standardized treatment of patients with HRF and ARDS is associated with increased ventilator-free days, lower tidal volume ventilation, and lower mortality. ICUs should consider the use of standardized treatment to improve the processes and outcomes of care for patients with HRF and ARDS.
CLINICAL TRIAL REGISTRATION
PROSPERO; No.: CRD42019099921; URL: www.crd.york.ac.uk/prospero/.
背景
低氧性呼吸衰竭（HRF）和急性呼吸窘迫综合征（ARDS）的治疗较为复杂。HRF 和 ARDS 的标准化管理可能有助于提高循证实践的依从性并改善预后。
研究问题
与常规护理相比，标准化治疗对 HRF 和 ARDS 患者的生存率有何影响？
研究设计和方法
检索 MEDLINE、EMBASE、Cochrane、CINAHL、Scopus 和 Web-of-Science（从创建到 2018 年）。纳入的研究为随机临床试验或准实验研究，比较了机械通气的成年 ICU 患者 HRF 或 ARDS 患者接受标准化治疗（护理方案、护理路径或护理包）与常规治疗的效果。两名评审员独立提取研究特征、路径组成部分和患者结局。
结果
从 15932 条独特的引文中共纳入 14 项研究进行系统评价（3 项随机临床试验和 11 项准实验研究）。12 项研究（包括 5767 名患者）纳入荟萃分析。HRF 的标准化管理与死亡率降低 23%相关（相对风险，0.77；95%CI，0.65-0.91；I²=70%；P=0.002）。在针对 ARDS 患者的研究（n=8）中，观察到死亡率降低 21%（相对风险，0.79；95%CI，0.71-0.88；I²=3.1%）。标准化管理与 28 天无呼吸机天数增加相关（加权均数差，3.48 天；95%CI，2.43-4.54 天；P<0.001）。标准化管理也与潮气量降低相关（加权均数差，-1.80mL/kg 预测体重；95%CI，-2.80 至-0.80mL/kg 预测体重；P<0.001）。元回归表明，死亡率的降低与提供更低的潮气量有关（P=0.045）。
解释
与常规治疗相比，HRF 和 ARDS 患者的标准化治疗与无呼吸机天数增加、更低的潮气量通气和更低的死亡率相关。重症监护病房应考虑使用标准化治疗来改善 HRF 和 ARDS 患者的护理流程和预后。
临床试验注册
PROSPERO；编号：CRD42019099921；网址：www.crd.york.ac.uk/prospero/。
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