加热湿化高流量鼻导管辅助通气治疗新生儿呼吸窘迫综合征有效性和安全性的Meta分析

Clinical efficacy and safety of heated humidified high-flow nasal cannula in neonatal respiratory distress syndrome: a meta-analysis

目的系统评价加热湿化高流量鼻导管辅助通气(HHHFNC)与经鼻持续气道正压通气(NCPAP)比较治疗新生儿呼吸窘迫综合征(NRDS)的有效性和安全性。方法计算机检索Pub Med、EMbase、The Cochrane Library(2017年3期)、CBM、VIP、Wan Fang Data和CNKI数据库,搜集HHHFNC与NCPAP比较治疗NRDS的随机对照试验(RCT),检索时限均从建库至2017年3月27日。由两位评价员独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用Rev Man 5.3软件进行Meta分析。结果共纳入11个研究,1 104例患者。Meta分析结果显示:(1)HHHFNC组能降低NRDS患儿重新插管率[OR=0.56,95%CI(0.32,0.98),P=0.04],缩短辅助通气时间[MD=–11.12,95%CI(–13.31,–8.93),P<0.000 01]、住院时间[MD=–2.99,95%CI(–3.54,–2.44),P<0.000 01]及开奶时间[MD=–17.82,95%CI(–21.19,–14.45),P<0.000 01],降低48小时动脉二氧化碳分压[MD=–4.86,95%CI(–5.94,–3.78),P<0.000 01]。HHHFNC组的气漏[OR=0.32,95%CI(0.12,0.90),P=0.03]、腹胀[OR=0.17,95%CI(0.09,0.30),P<0.000 01]、鼻损伤[OR=0.08,95%CI(0.03,0.20),P<0.000 01]、头部塑形[OR=0.03,95%CI(0.00,0.23),P=0.000 7]的发生率均低于NCPAP组,其差异均有统计学意义。(2)HHHFNC组与NCPAP组在病死率、院内感染率、氧暴露时间、48小时动脉氧分压及血氧饱和度及脑室内出血(IVH)、动脉导管未闭(PDA)、早产儿视网膜病(ROP)、支气管肺发育不良(BPD)、新生儿坏死性小肠结肠炎(NEC)的发生率方面,差异均无统计学意义。结论现有证据表明,HHHFNC能降低NRDS的重新插管率,缩短辅助通气时间、住院时间及开奶时间,降低48小时动脉二氧化碳分压,并且降低气漏、腹胀、鼻损伤、头部塑形的发生率。受纳入研究数量和质量限制,有关HHHFNC对NRDS的远期疗效仍有待大规模、多中心的RCT予以验证。

Objective To evaluate the efficacy and safety of heated humidified high-flow nasal cannula （HHHFNC） vs. nasal continuous positive airway pressure （NCPAP） in the treatment of neonatal respiratory distress syndrome （NRDS）. Methods The PubMed, EMbase, The Cochrane Library （Issue 3, 2017）, CBM, VIP, WanFang Data and CNKI were searched up to March 27th, 2017 to collect randomized controlled trials （RCTs） of HHHFNC vs. NCPAP for NRDS. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies. Then, meta-analysis was performed by RevMan 5.3 software. Results A total of 11 RCTs involving 1 104 patients were included. The results of meta-analysis showed that： 1） The HHHFNC group reduced the rate of reintubation （OR=0.56, 95%CI 0.32 to 0.98, P=0.04）, shortened the time of assisted ventilation （MD=-11.12, 95%CI -13.31 to -8.93, P〈0.000 01）, hospitalization time （MD=-2.99, 95%CI -3.54 to -2.44, P〈0.000 01） and neonatal aspiration of milk （MD=-17.82, 95%CI -21.19 to -14.45, P〈0.000 01）, shortened partial pressure of carbon dioxide at 48 hours （MD=-4.86,95%CI -5.94 to -3.78, P〈0.000 01）, reduced the rate of frequent hemorrhoid （OR=0.32, 95%CI 0.12 to 0.90, P=0.03）, the rate of abdominal distension （OR=0.17, 95%CI 0.09 to 0.30, P〈0.000 01）, the rate of injury of nose （OR=0.08, 95%CI 0.03 to 0.20, P〈0.000 01）, and the rate of head shape change （OR=0.03, 95%CI 0.00 to 0.23, P=0.000 7）. 2） There were no significant differences between two groups in mortality rate, nosocomial infection rate, oxygen exposure time, arterial oxygen pressure and oxygen saturation at 48 hours, intraventricular hemorrhage, patent ductus arteriosus, retinopathy of prematurity, bronchopulmonary dysplasia and neonatal necrotizing enterocolitis, respectively. Conclusion Current evidence indicates that HHHFNC can reduce the rate of reintubation, shorten the time of assisted ventilation, length of hospital day and neonatal aspiration of milk, reduce the rate of frequent hemorrhoid, abdominal distension, injury of nose, head shape change. Due to the limitation of quantity and quality of included studies, the long-term follow-up results of HHHFNC for NRDS are needed to analyze with large-scale and multicenter RCTs.