文化对新型冠状病毒肺炎急性呼吸窘迫综合征成人患者清醒俯卧位通气益处的影响：一项系统评价与荟萃分析
The effect of culture on the benefits of awake prone positioning for adults with COVID-19 acute respiratory distress syndrome: A systematic review and meta-analysis.
作者信息
Karanth Sowmyashree Kota, Azhar Saajid Z, Corrales-Martinez Maria J, Krishnamoorthy Vijay, Wongsripuemtet Pattrapun T, Cobert Julien, Hashemaghaie Mona, Raghunathan Karthik
机构信息
From the Department of Anesthesiology, Duke University, Durham, North Carolina (SKK, MJC-M, VK, PTW, MH, KR), Department of Emergency Medicine, Louisiana State University Health Sciences Center Shreveport, Shreveport, Lousiana (SZA) and Department of Anesthesiology, University of California, San Francisco, California, USA (JC).
出版信息
Eur J Anaesthesiol Intensive Care. 2025 Feb 5;4(2):e0068. doi: 10.1097/EA9.0000000000000068. eCollection 2025 Apr.
BACKGROUND
Randomised controlled trials (RCTs) conducted early during the pandemic showed that awake prone positioning (APP) significantly reduced the risk of intubation among adults with COVID-19 acute respiratory distress syndrome (ARDS), but more recent studies have questioned this benefit. We hypothesise that the effects of APP may vary with the national Power Distance Index (PDI), a measure of hierarchy in local culture.
OBJECTIVE
To conduct a meta-analysis examining the effects of APP in adults with COVID-19 ARDS and examine whether effects differ between nations with a PDI less than 80 versus at least 80 (low versus high deference to authority).
DESIGN
Systematic review and meta-analysis of RCTs.
DATA SOURCES
Cumulated Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, Embase, Medline and Scopus were searched to November 2024.
ELIGIBILITY CRITERIA
All RCTs that compared APP with standard care in adults with COVID-19-related ARDS or Acute Hypoxaemic Respiratory Failure (AHRF) were included.
RESULTS
Twenty-two RCTs were identified with 3615 patients having valid data. APP reduced the risk of intubation [relative risk (RR) 0.80, 95% confidence interval (CI), 0.72 to 0.90]. Effects were greater in nations with a PDI at least 80 (RR 0.67, 95% CI, 0.54 to 0.82), and there was equipoise in nations with a PDI less than 80 (RR 0.89, 95% CI, 0.75 to 1.05). Intubation rates in the high PDI nations decreased from 32.3% ( = 512) with standard care to 21.2% ( = 508) with APP. The reduction in intubations with APP was less pronounced in nations with low PDI, from 20.1% ( = 1012) with standard care to 17.1% ( = 1084). The risk of mortality reduced with APP (RR 0.86, 95% CI, 0.74 to 0.99). Fidelity of APP, specifically, adherence to the recommended duration, was higher in nations with PDI at least 80 ( = 0.04).
CONCLUSION
APP reduces the risk of intubation and mortality, but the significance of this benefit varies with the cultural context. Effects are strong in nations with a higher PDI, where intubation rates are lower and adherence to APP higher.
背景
疫情早期进行的随机对照试验（RCT）表明，清醒俯卧位通气（APP）显著降低了新冠病毒19型急性呼吸窘迫综合征（ARDS）成人患者的插管风险，但最近的研究对此益处提出了质疑。我们假设，APP的效果可能因国家权力距离指数（PDI）而异，该指数是衡量当地文化等级制度的指标。
目的
进行一项荟萃分析，研究APP对新冠病毒19型ARDS成人患者的影响，并探讨PDI小于80与至少80的国家（对权威的低与高顺从程度）之间的效果是否存在差异。
设计
对RCT进行系统评价和荟萃分析。
数据来源
检索了截至2024年11月的护理及相关健康文献累积索引（CINAHL）、考克兰图书馆、Embase、Medline和Scopus。
纳入标准
纳入所有比较APP与标准治疗对新冠病毒19型相关ARDS或急性低氧性呼吸衰竭（AHRF）成人患者影响的RCT。
结果
确定了22项RCT，3615例患者有有效数据。APP降低了插管风险[相对风险（RR）0.80，95%置信区间（CI），0.72至0.90]。在PDI至少为80的国家，效果更大（RR 0.67，95%CI，0.54至0.82），而在PDI小于80的国家则无明显差异（RR 0.89，95%CI，0.75至1.05）。高PDI国家的插管率从标准治疗时的32.3%（n = 512）降至APP治疗时的21.2%（n = 508）。在低PDI国家，APP降低插管率的效果不太明显，从标准治疗时的20.1%（n = 1012）降至17.1%（n = 1084）。APP降低了死亡风险（RR 0.86，95%CI，0.74至0.99）。具体而言，在PDI至少为80的国家，APP的依从性，即对推荐持续时间的遵守情况更高（P = 0.04）。
结论
APP降低了插管和死亡风险，但这种益处的显著性因文化背景而异。在PDI较高的国家，效果显著，插管率较低且对APP的依从性较高。
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