预防性静脉应用皮质激素防止成人拔管后气道并发症：随机、安慰剂对照研究的荟萃分析

Prophylactic administration of parenteral steroids for preventing airway complications after extubation in adults： meta-analysis of randomised placebo controlled trials

目的确定皮质激素是否可有效预防成年危重症患者拔管后喉部水肿，并降低因喉部水肿导致的再插管。设计荟萃分析。数据来源：检索数据库PubMed，Cochrane Controlled Trials Register，Web of Science，and Embase，对语言、研究时间和发表状态没有限制。选择标准关于静脉使用皮质激素预防成年患者拔管后并发症的随机、安慰剂对照研究。回顾方法检索并根据纳入和排除标准选择文献、提取数据、评估方法学的可靠性，然后进行独立分析并重复。汇总分析数据得到优势比和95％可信区间，风险差异和需治数。研究终点：主要终点：拔管后发生喉部水肿。次要终点：由于喉部水肿导致的再插管。结果6项临床研究纳入分析（n=1923）。与安慰剂组相比，拔管前应用激素可降低喉部水肿（OR=0．38，95％可信区间为0．17～0．85）和再插管（OR=0．29，95％可信区间为0．15～0．58）的发生率，相应的风险差异分别为-0．10（-0．12～-0．07；需治数为10）和-0．02（-0．04～-0．01;需治数为50）。亚组分析显示，多次给药可明显降低喉部水肿（OR=0．14，95％可信区间为0．08～0．23）和再插管（OR=0．19，95％可信区间为0．07～0．50）的发生率，相应的风险差异分别为-0．19（-0．24--0．15；需治数为5）和-0．04（-0．07--0．02；需治数为25）。单次给药只发现有降低喉部水肿和再插管发生率的趋势，可信区间包含1。没有报道激素相关的副作用。结论成年患者拔管前预防性多次给予皮质激素可降低拔管后喉部水肿和因其所致再插管的发生率，且很少引发不良事件。

Objective To determine whether steroids are effective in preventing laryngeal oedema after extubation and reducing the need for subsequent reintubation in critically ill adults. Design Meta-analysis. Data sources PubMed, Cochrane Controlled Trials Register, Web of Science, and Embase with no limitation on language, study year, or publication status. Selection criteria Randomised placebo controlled trials in which parenteral steroids were compared with placebo for preventing complications after extubation in adults. Review methods Search, application of inclusion and exclusion criteria, data extraction, and assessment of methodological quality, independently performed in duplicate. Odds ratios with 95% confidence intervals, risk difference, and number needed to treat were calculated and pooled. Main outcome measures Primary outcome： laryngeal oedema after extubation. Secondary outcome ： subsequent reintubation because of laryngeal oedema. Results Six trials （ n = 1923 ） were identified. Compared with placebo, steroids given before planned extubation decreased the odds ratio for laryngeal oedema （0.38, 95% confidence interval 0. 17 to 0. 85） and subsequent reintubation （0.29, 0. 15 to 0.58）, corresponding with a risk difference of -0.10 （ -0. 12 to -0.07; number needed to treat 10） and -0.02 （ -0.04 to -0.01; 50）, respectively. Subgroup analyses indicated that a multidose regimen of steroids had marked positive effects on the occurrence of laryngeal oedema （0. 14; 0. 08 to 0. 23） and on the rate of subsequent reintubation （0. 19; 0. 07 to 0. 50 ）, with a risk difference of -0. 19 （ -0.24 to -0. 15; 5） and -0.04 （ -0.07 to -0. 02; 25 ）. In single doses there was only a trend towards benefit, with the confidence interval including 1. Side effects related to steroids were not found. Conclusion Prophylactic administration of steroids in multidose regimens before planned extubation reduces the incidence of laryngeal oedema after extubation and the consequent reintubation rate in adults, with few adverse events.