慢性阻塞性肺疾病急性加重患者撤机后序贯使用经鼻高流量氧疗对比无创正压通气临床疗效的Meta分析

Clinical efficacy of sequential HFNC versus NIPPV after extubation in AECOPD patients:a meta-analysis of randomized controlled trials

目的系统评价慢性阻塞性肺疾病急性加重(acute exacerbation of chronic obstructive pulmonary disease,AECOPD)患者撤机后序贯经鼻高流量氧疗(high-flow nasal cannula oxygen therapy,HFNC)的临床疗效。方法检索国内外数据库关于AECOPD患者拔管后使用HFNC的随机对照临床试验(randomized controlled trials,RCTs),试验组采用HFNC,对照组采用无创正压通气(non-invasive positive pressure ventilation,NIPPV)。主要结局指标:再次插管率;次要结局指标:拔管后氧合指数、重症加强治疗病房(intensive care unit,ICU)住院时间、病死率、舒适度评分、不良反应发生率。使用RevMan 5.3软件进行统计分析。结果纳入20篇文献,共1516例研究对象,HFNC 754例,NIPPV 762例。Meta分析结果显示:HFNC组与NIPPV组,在再次插管率(RR=1.41,95%CI 0.97~2.07,P=0.08)、死亡率(RR=0.91,95%CI 0.58~1.44,P=0.69)上的差异并无统计学意义,而在拔管后24 h氧合指数(MD=4.66,95%CI 0.26~9.05,P=0.04)、ICU住院时间(高危组:SMD–0.52,95%CI–0.74~–0.30;中低危组:MD–1.12,95%CI–1.56~–0.67;P值均<0.00001)、舒适度评分(MD=1.90,95%CI 1.61~2.19,P<0.00001)、不良反应发生率(RR=0.22,95%CI 0.16~0.31,P<0.00001)方面,HFNC组优于NIPPV组。结论与NIPPV相比,HFNC并未增加气管再插管率、病死率的风险,但可更好地改善拔管后氧合指数,缩短ICU住院时间,有效提高患者舒适度,减少不良反应发生,提示HFNC可以谨慎尝试运用于AECOPD患者撤机后的序贯治疗,特别是不能耐受NIPPV者。

Objective To systematically evaluate the efficacy of high-flow nasal cannula oxygen therapy(HFNC)in Post-extubation acute exacerbation of chronic obstructive pulmonary disease(AECOPD)patients.Methods The Domestic and foreign databases were searched for all published available randomized controlled trials(RCTs)about HFNC therapy in post-extubation AECOPD patients.The experimental group was treated with HFNC,while the control group was treated with non-invasive positive pressure ventilation(NIPPV).The main outcome measurements included reintubation rate.The secondary outcomes measurements included oxygenation index after extubation,length of intensive care unit(ICU)stay,mortality,comfort score and adverse reaction rate.Meta-analysis was performed by Revman 5.3 software.Result A total of 20 articles were enrolled.There were 1516 patients enrolled,with 754 patients in HFNC group,and 762 patients in control group.The results of Meta-analysis showed that there were no significant difference in reintubation rate[RR=1.41,95%CI 0.97-2.07,P=0.08]and mortality[RR=0.91,95%CI 0.58-1.44,P=0.69].Compared with NIPPV,HFNC have advantages in 24 h oxygenation index after extubation[MD=4.66,95%CI 0.26-9.05,P=0.04],length of ICU stay[High risk group:SMD–0.52,95%CI–0.74-–0.30;Medium and low risk group:MD–1.12,95%CI–1.56-–0.67;P<0.00001],comfort score[MD=1.90,95%CI 1.61-2.19,P<0.00001]and adverse reaction rate[RR=0.22,95%CI 0.16-0.31,P<0.00001].Conclusions Compared with NIPPV,HFNC could improve oxygenation index after extubation,shorten the length of ICU stay,effectively improve Patient comfort,reduce the occurrence of adverse reactions and it did not increase the risk of reintubation and mortality.It is suggested that HFNC can be cautiously tried for sequential treatment of AECOPD patients after extubation,especially those who cannot tolerate NIPPV.