肥胖重症成年患者拔管后的无创呼吸支持：一项系统评价和网状Meta分析

Noninvasive respiratory support following extubation in critically ill adults with obesity: a systematic review and network meta-analysis.

作者信息

Pensier Joris, Naudet-Lasserre Arthur, Monet Clément, Capdevila Mathieu, Aarab Yassir, Lakbar Inès, Chanques Gérald, Molinari Nicolas, De Jong Audrey, Jaber Samir

机构信息

Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Montpellier, CEDEX 5, France.

PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR, 9214, Montpellier, France.

出版信息

EClinicalMedicine. 2024 Dec 16;79:103002. doi: 10.1016/j.eclinm.2024.103002. eCollection 2025 Jan.

DOI:10.1016/j.eclinm.2024.103002

PMID:39791108

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC11715126/

Abstract

BACKGROUND

Patients with obesity are at high-risk of extubation failure. Discrepancies were found in the results of recent randomized controlled trials (RCTs) regarding the roles of noninvasive ventilation (NIV), high flow nasal cannula (HFNC) and conventional oxygen therapy (COT) to prevent extubation failure in critically ill patients with obesity.

METHODS

In this systematic review and network meta-analysis, we searched MEDLINE, Cochrane Center Register of Controlled Trials and Web of Science from 1 January 1998 to 1 July 2024 for RCTs evaluating noninvasive respiratory support therapies (NIV, HFNC, COT, NIV + HFNC) after extubation in critically ill adults with obesity. Primary outcome was reintubation at day 7. Secondary outcome was 28-day mortality. We generated pooled risk ratios (RR) and numbers needed to treat (NNT). We rated risk of bias using the Cochrane risk-of-bias 2.0 tool. The study was registered with PROSPERO (CRD 42022308995).

FINDINGS

In seven RCTs including 1933 patients, NIV + HFNC (RR 0.36 [95% confidence interval (CI) 0.16-0.82], NNT = 10 [95% CI 7-33]) and NIV (RR 0.45 [95% CI 0.23-0.88], NNT = 11 [95% CI 8-50]) but not HFNC (RR 0.79 [95% CI 0.40-1.59]) reduced reintubation at day 7, compared to COT. Compared to HFNC, NIV + HFNC (RR 0.46 [95% CI 0.23-0.90], NNT = 14 [95% CI 10-77]) but not NIV (RR 0.57 [95% CI 0.32-1.02]) reduced reintubation at day 7. Compared to HFNC, both NIV (RR 0.31 [95% CI 0.13-0.74], NNT = 15 [95% CI 12-40]) and NIV + HFNC (RR 0.30 [95% CI 0.10-0.89], NNT = 15 [95% CI 11-90]) reduced 28-day mortality.

INTERPRETATION

The results suggest that compared to COT and HFNC, NIV alone or with HFNC reduces reintubation in critically ill patients with obesity after extubation. Compared to HFNC, NIV alone or with HFNC reduces mortality. The number needed to treat with NIV or NIV + HFNC to avoid one death was 15. These findings support the application of NIV to mitigate extubation failure in critically ill adults with obesity.

FUNDING

None.

摘要

背景

肥胖患者拔管失败风险较高。近期关于无创通气（NIV）、高流量鼻导管吸氧（HFNC）和传统氧疗（COT）在预防肥胖重症患者拔管失败中作用的随机对照试验（RCT）结果存在差异。

方法

在这项系统评价和网状Meta分析中，我们检索了1998年1月1日至2024年7月1日期间的MEDLINE、Cochrane对照试验中心注册库和科学网，以查找评估肥胖成年重症患者拔管后无创呼吸支持疗法（NIV、HFNC、COT、NIV + HFNC）的RCT。主要结局是第7天再次插管。次要结局是28天死亡率。我们计算了合并风险比（RR）和治疗所需人数（NNT）。我们使用Cochrane偏倚风险2.0工具评估偏倚风险。该研究已在PROSPERO注册（CRD 42022308995）。

结果

在纳入1933例患者的7项RCT中，与COT相比，NIV + HFNC（RR 0.36 [95%置信区间（CI）0.16 - 0.82]，NNT = 10 [95% CI 7 - 33]）和NIV（RR 0.45 [95% CI 0.23 - 0.88]，NNT = 11 [95% CI 8 - 50]）可降低第7天再次插管的发生率，但HFNC（RR 0.79 [95% CI 0.40 - 1.59]）无此作用。与HFNC相比，NIV + HFNC（RR 0.46 [95% CI 0.23 - 0.90]，NNT = 14 [95% CI 10 - 77]）可降低第7天再次插管的发生率，但NIV（RR 0.57 [95% CI 0.32 - 1.02]）无此作用。与HFNC相比，NIV（RR 0.31 [95% CI 0.13 - 0.74]，NNT = 15 [95% CI 12 - 40]）和NIV + HFNC（RR 0.30 [95% CI 0.10 - 0.89]，NNT = 15 [95% CI 11 - 90]）均可降低28天死亡率。