早期气管切开和晚期气管切开／延迟气管插管对需长期机械通气的重症患者预后影响的系统分析

Early versus late tracheostomy/prolonged intubation on the outcomes of patients undergoing prolonged mechanical ventilation： a meta - analysis

目的评价早期和晚期气管切开／延迟气管插管对需长期机械通气的重症患者预后的影响。方法应用Meta分析方法对国内外关于早期和晚期气管切开／延迟气管插管对需长期机械通气重症患者的预后影响进行定量的综合分析；运用Revman5．2进行异质性检验及合并OR值和95％可信区间的计算。结果最终纳入10篇文献，包括2121例患者，其中5篇RCT是比较早期和晚期气管切开，5篇RCT是比较早期气管切开和延迟气管插管对需长期机械通气重症患者的预后影响。Meta分析结果显示，早期气管切开均不能降低长期机械通气患者的短期病死率（P=0．07）、长期病死率（P=0．47）、机械通气时间（P=0．29）及并发症（P=0．73）。但仅与晚期气管切开比较，早期气管切开可以提高患者成功撤机率（P=0．004）、ICU转出率（P=0．005），降低呼吸机相关肺炎的发生率（P=0．0003）。结论早期气管切开不能降低患者病死率、机械通气时间及并发症，但可提高成功撤机率、ICU转出率同时降低呼吸机相关肺炎发生率。临床医生需根据危重患者的实际情况决定是否需长期辅助机械通气治疗而行早期气管切开。

Objective To evaluate the effect of early tracheostomy （ET） versus late tracheostomy （LT）/prolonged intubation （PI） on the outcomes of patients undergoing prolonged mechanical ventilation （PMV）. Methods An electronic search （last search： June 1, 2013 ） was conducted using uniform requirements and the clinical data satisfied the inclusion criteria were extracted. Statistical analysis was performed by Revman 5.2 and risk ratio, mean difference, and standardized mean difference statistics. Results Ten randomized controlled trials （RCTs） including 2121 adult patients, of whom LT were conducted on 1059 were extracted. Five studies compared ET with LT. Five studies compared ET with PI. No significant mortality differences were found between the ET groups and the LT or PI groups （ short - term mortality ： P = 0.07, long - term mortality ： P = 0.47 ） and both in the subgroup. Additionally, no significant differences in MV duration （WMD = - 2.04, 95% CI = - 5.85 to 1.77, P = 0.29）, complications or side - effects were observed （RR = 1.03, 95% CI = 0.86 to 1.24, P = 0.73 ）. ET, however, significantly increased the successful weaning ratio （RR = 1.18, 95% CI=1.05 tol.31, P=0.004） and ICU discharge rate （RR=l.27, 95% CI=1.06 to 1.53, P= 0. 009） in the five studies that enrolled only LT patient groups （ i. e. , no PI groups）. A similar finding was observed regarding VAP （RR=0.57, 95% CI=0.42 to0.78, P=0.0003）. Conclusion ET in critical ill patients who were anticipated to require PMV significantly increases the successful - weaning ICU discharge and VAP ratios when compared with LT. ET, however, does not significantly reduce patient mortality, MV duration, complications or side - effects. In the observed RCTs, the clinicians are able to make clinical judgment decisions to predict whether PMV is essential; however, additional high quality RCTs are required to confirm this finding.