家庭无创通气对重度慢性阻塞性肺疾病稳定期患者疗效的荟萃分析

Effect of home noninvasive positive pressure ventilation on patients with severe stable chronic obstructive pulmonary disease： a meta-analysis

目的采用荟萃分析方法研究家庭无创正压通气在重度慢性阻塞性肺疾病（慢阻肺）稳定期患者中的应用疗效。 方法检索美国国立医学图书馆PubMed、荷兰医学文摘EMBASE、Cochrane临床试验数据库、万方数据库、维普数据库、中国期刊全文数据库，自1980年1月至2016年1月发表的有关家庭无创正压通气用于重度慢阻肺稳定期患者疗效比较的随机对照试验。应用Revman 5.3软件进行统计分析，根据吸气压力的高低、实际使用时间的长短和基础PaCO2的水平进行亚组分析。 结果最终纳入10篇文献，共789例患者，家庭无创通气可提高患者的6 min步行距离[加权均数差（WMD）：－45.12，95%CI为－85.39～－4.85，P＝0.03]，提高患者随访期1年时的FEV1[标准均数差（SMD）：－0.26，95%CI为－0.51～－0.02，P＝0.03]，对患者病死率、PaCO2、PaO2、pH、FEV1、FVC、最大吸气压（MIP）、FEV1/FVC、最大自主通气量（MVV）、总的睡眠时间、睡眠有效率、快动眼睡眠时间比例等评价指标均无显著影响。亚组分析结果显示，在高吸气压力组[≥18 cmH2O，（1 cmH2O＝0.098 kPa）]、实际使用时间≥5 h组以及高PaCO2水平组[基线值≥55 mmHg（1 mmHg＝0.133 kPa）]中，家庭无创通气显著降低患者的PaCO2。 结论家庭无创通气可以提高患者的6 min步行距离和FEV1，但并不能降低患者的病死率，对血气分析结果和睡眠质量无影响。更高的吸气压力、更长的使用时间和患者基础PaCO2越高，可能有助于降低患者的PaCO2。

ObjectiveTo evaluate the effect of home noninvasive positive pressure ventilation （NPPV） on patients with severe stable chronic obstructive pulmonary disease（COPD） by meta-analysis. MethodsThe data of this meta-analysis was retrieved from the PubMed, EMBASE, Cochrane library, Wanfang, Weipu and CNKI databases from January 1980 to January 2016. Randomized controlled trials （RCTs） on comparison of the effect of home NPPV in patients with severe stable COPD were enrolled. The enrolled data were divided into different subgroups in terms of the levels of inspiratory positive airway pressure（IPAP）, different duration of ventilation per day, and different levels of baseline hypercapnia on change in PaCO2. Meta-analysis was performed to compare the effect of different subgroups by RevMan 5.3. ResultsTen studies with a total of 789 patients were included. Home NPPV improved 6-minute walk distance （WMD： -45.12, 95%CI： -85.39--4.85, P=0.03） and forced expiratory volume in the first second [standard mean difference（SMD）： -0.26, 95%CI： -0.51--0.02, P=0.03]after 1 year of ventilation, but did not improve the mortality, PaCO2,PaO2,pH, FVC, maximal inspiratory pressure （MIP）, FEV1/FVC, maximal voluntary ventilation（MVV） total sleep time, sleep efficiency and the proportion of rapid eye movement （REM） sleep. Subgroup analysis showed that home NPPV can significantly reduce the PaCO2 in patients ventilated with 18 cmH2O（1 cmH2O=0.098 kPa） and higher IPAP levels than those with lower IPAP levels （SMD： -0.6, 95%CI： -1.09--0.12, P=0.01）, and in patients with NPPV for at least 5 h per day and those with lower duration （SMD： -0.45, 95%CI： -0.87--0.02, P=0.04）, and in patients with baseline PaCO2 of at least 55 mmHg （1 mmHg=0.133 kPa） （SMD： -0.69, 95%CI： -1.07--0.31, P=0.00） than those with lower levels. ConclusionsHome NPPV can improve 6MWD and FEV1 in severe stable COPD patients but does not improve the mortality, gas exchange and sleep efficiency. Patients may gain more benefits when using higher IPAP levels, longer ventilation per day and in those with higher baseline PaCO2.