气管切开时机对长期机械通气患者影响的Meta分析

Impact of the timing of tracheostomy on patients treated with prolonged mechanical ventilation--A metaanalysis of randomized and quasi-randomized controlled trials

目的评价早期气管切开和延迟气管切开对长期机械通气（prolonged mechanical ventilation，PMV）患者。方法计算机检索Ovide MEDLINE（1966-2006．07）、EMBASE（1980-2006．07）、Cochrane Database（2006年第2期）、中国Cochrane中心临床对照试验资料数据库，中国生物医学文献光盘数据库（1978-2006．07）。手工检索初步入选文献的全文和参考文献中所列的相关文献和杂志、学术会议论文集、学位论文汇编。收集国内外关于不同气管切开时机对PMV患者影响的随机和半随机对照试验，并进行方法学质量评价，用RevMan4．2软件进行Meta分析。结果共检索到随机对照试验（randomized controlled trials，RCrs）4个，病例286例；半随机对照实验（quasi．RCrs）1个，病例106例。合并结果显示，早期气管切开可以降低PMV患者的死亡率[RR0．69，95％CI（O．51，0．95）]，减少机械通气（mechanical ventilation，MV）时间[WMD-8．49，95％CI（-15．32，-1．66）]和ICU住院时间[WMD-15．33，95％CI（-24．58，-6．08）]，但对医院获得性肺炎的发病率无显著影响[RR0．91，95％CI（0．70，1．18]。结论现有证据表明，早期气管切开可以降低PMV患者的死亡率，减少MV时间和ICU住院时间，但对医院获得性肺炎的发病率没有显著影响。

Objective To compare the early and delayed tracheostomy in patients treated with prolonged mechanical ventilation in respects of mortality, incidence of nosocomial pneunonia and length of ICU stay. Methods Randomized controlled trials （RCTs） and quasi-randomized controlled trials （quasi-RCTs） were performed by searching through the Ovide MEDLINE （1996-2006.7）, EMBASE （1980-2006.7）, Cochrane Database （Issue 2, 2006）, Chinese Cochrane Centre Database and CBMdisc （1978-2006.7）. The published and unpublished data and their references were searched. All RCTs and quasi-RCTs of tracheostomy for critically ill patients treated withprolonged mechanical ventilation were included. Data were collected and evaluated by two reviewers independently and separately. RevMan version 4.2 software was used for data analysis. Results Two hundred and eighty-six patients from 4 RCTs and 106 cases from one quasi-RCT were taken for meta analysis. The meta-analysis showed that the early tracheostomy could reduce mortality （OR 0.69, 95% CI 0.51, 0.95）, significantly shorten the duration of mechanical ventilation （WMD - 8.49, 95% CI - 15.32, - 1.66） and shorten the length of ICU stay as well （WMD - 15.33, 95% CI - 24.58, - 6.08） in patients treated with prolonged mechanical ventilation, but the incidence of nosocomial pneumonia was not different between two sorts of patients （OR 0.91, 95% CI 0.70, 1.18）. Conclusions In case of prolonged mechanical ventilation, the tracheostomy performed at earlier stage may decrease the mortality, and shorten the duration of mechanical ventilation and the length of ICU stay, but cannot reduce the incidence of nosocomial pneumonia.