Zheng Xiaozhuo, Wang Rui, Giri Mohan, Duan Jun, Ma Mengyi, Guo Shuliang
Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
Department of Thoracic Surgery, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China.
Front Med (Lausanne). 2022 Oct 13;9:1026234. doi: 10.3389/fmed.2022.1026234. eCollection 2022.
Extubation failure is common in critically ill patients, especially those with high-risk factors, and is associated with poor prognosis. Prophylactic use of oxygen therapy after extubation has been gradually introduced. However, the best respiratory support method is still unclear.
This study aimed to evaluate the efficacy of four post-extubation respiratory support approaches in reducing reintubation and respiratory failure in patients at high-risk of extubation failure.
A comprehensive search was performed in Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and Web of Science from inception to June 2022. Randomized controlled trials (RCTs) comparing post-extubation preventive use of respiratory management strategies, including conventional oxygen therapy (COT), non-invasive ventilation (NIV), and high-flow nasal catheter (HFNC) in high-risk patients with extubation failure were reviewed. Primary outcomes were reintubation rate and respiratory failure. Secondary outcomes included intensive care unit (ICU) mortality, ICU stay and length of hospital stay (LOS).
Seventeen RCTs comprising 2813 participants were enrolled. Compared with COT, the three respiratory support methods (NIV, HFNC, NIV + HFNC) were all effective in preventing reintubation [odds ratio (OR) 0.46, 95% confidence interval (CI) 0.32-0.67; OR 0.26, 95% CI 0.14-0.48; OR 0.62, 95% CI 0.39-0.97, respectively] and respiratory failure (OR 0.23, 95% CI 0.10-0.52; OR 0.15, 95% CI 0.04-0.60; OR 0.26, 95% CI 0.10-0.72, respectively). NIV and NIV + HFNC also reduced ICU mortality (OR 0.40, 95% CI 0.22-0.74; OR 0.32, 95% CI 0.12-0.85). NIV + HFNC ranked best in terms of reintubation rate, respiratory failure and ICU mortality based on the surface under the cumulative ranking curve (SUCRA) (99.3, 87.1, 88.2, respectively). Although there was no significant difference in shortening ICU stay and LOS among the four methods, HFNC ranked first based on the SUCRA.
Preventive use of NIV + HFNC after scheduled extubation is probably the most effective respiratory support method for preventing reintubation, respiratory failure and ICU death in high-risk patients with extubation failure. HFNC alone seems to be the best method to shorten ICU stay and LOS.
[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022340623].
拔管失败在重症患者中很常见，尤其是那些具有高危因素的患者，并且与预后不良相关。拔管后预防性使用氧疗已逐渐被采用。然而，最佳的呼吸支持方法仍不明确。
本研究旨在评估四种拔管后呼吸支持方法在降低拔管失败高危患者再插管率和呼吸衰竭方面的疗效。
从创刊至2022年6月，在Cochrane对照试验中央登记库、PubMed、EMBASE和科学网进行了全面检索。对比较拔管后预防性使用呼吸管理策略（包括传统氧疗（COT）、无创通气（NIV）和高流量鼻导管（HFNC））在拔管失败高危患者中的随机对照试验（RCT）进行了综述。主要结局是再插管率和呼吸衰竭。次要结局包括重症监护病房（ICU）死亡率、ICU住院时间和住院时间（LOS）。
纳入了17项RCT，共2813名参与者。与COT相比，三种呼吸支持方法（NIV、HFNC、NIV+HFNC）在预防再插管[优势比（OR）分别为0.46，95%置信区间（CI）0.32 - 0.67；OR 0.26，95%CI 0.14 - 0.48；OR 0.62，95%CI 0.39 - 0.97]和呼吸衰竭（OR分别为0.23，95%CI 0.10 - 0.52；OR 0.15，95%CI 0.04 - 0.60；OR 0.26，95%CI 0.10 - 0.72）方面均有效。NIV和NIV + HFNC也降低了ICU死亡率（OR分别为0.40，95%CI 0.22 - 0.74；OR 0.32，95%CI 0.12 - 0.85）。基于累积排名曲线下面积（SUCRA），NIV + HFNC在再插管率、呼吸衰竭和ICU死亡率方面排名最佳（分别为99.3、87.1、88.2）。尽管四种方法在缩短ICU住院时间和LOS方面没有显著差异，但基于SUCRA，HFNC排名第一。
计划性拔管后预防性使用NIV + HFNC可能是预防拔管失败高危患者再插管、呼吸衰竭和ICU死亡的最有效呼吸支持方法。单独使用HFNC似乎是缩短ICU住院时间和LOS的最佳方法。
