术中通气策略可预防术后肺部并发症
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Intraoperative ventilation strategies to prevent postoperative pulmonary complications: a network meta-analysis of randomised controlled trials
背景与目的
目前外科手术患者肺保护性通气策略的观点很多。有研究表明使用低潮气量（VT）可提高临床疗效。然而，低VT通气中的最佳呼气末正压通气（PEEP）水平和匹配策略（RM）仍不清楚。
方 法
通过检索多个电子数据库纳入相关随机对照试验（RCT），这些RCT比较低VT通气策略和常规机械通气（CMV）之间的差异，或外科手术患者中两种不同的低VT策略之间的差异。主要结果是术后肺部并发症（PPCs）。次要结果是肺不张、肺炎、急性呼吸窘迫综合征和近期死亡率。使用WinBUGS进行meta分析，计算优势比（ORs）和相应的95%可信区间（CrIs）。
结 果
与CMV相比，低VT通气+中高PEEP可降低PPCs的风险,（中等PEEP(5-8cmH2O):OR=0.50;95%CrIs:0.28-0.89；中等PEEP+RMs:OR=0.39;95%CrIs:0.19-0.78；高PEEP(>9cmH2O+ RMs:OR=0.34,95% CrIs:0.14-0.79）。与CMV相比，低VT通气伴中度PEEP和RMs也能显著降低肺不张的风险，而低VT通气伴中度PEEP在降低肺炎风险方面优于CMV。
结 论
对于全身麻醉的外科手术患者，低VT通气和中高PEEP（≥5cm H2O）的联合应用有助于肺保护。
原始文献摘要
Deng QW, Tan WC, Zhao BC；Intraoperative ventilation strategies to prevent postoperative pulmonary complications: a network meta-analysis of randomised controlled trials；Br J Anaesth 2020 Mar;124(3)；PMID：32007240
Background: The debate on lung-protective ventilation strategies for surgical patients is ongoing. Evidence suggests that the use of low tidal volume VT improves clinical outcomes. However, the optimal levels of PEEP and recruitment manoeuvre (RM) strategies incorporated into low VT ventilation remain unclear.
Methods: Several electronic databases were searched to identify RCTs that focused on comparison between low VT strategy and conventional mechanical ventilation (CMV), or between two different low VT strategies in surgical patients. The primary outcome was postoperative pulmonary complications (PPCs). The secondary outcomes were atelectasis, pneumonia, acute respiratory distress syndrome, and short-term mortality. Bayesian network meta-analyses were performed using WinBUGS. The odds ratios (ORs) and corresponding 95% credible intervals (CrIs) were estimated.
Results: Compared with CMV, low VT ventilation with moderate-to-high PEEP reduced the risk of PPCs (moderate PEEP [5-8 cm H2O]: OR 0.50 [95% CrI: 0.28, 0.89]; moderate PEEP+RMs: 0.39 [0.19, 0.78]; and high PEEP [≥9 cm H2O]+RMs: 0.34 [0.14, 0.79]). Low VT ventilation with moderate-to-high PEEP and RMs also specififically reduced the risk of atelectasis compared with CMV (moderate PEEP+RMs: OR 0.36 [95% CrI: 0.16, 0.87]; and high PEEP+RMs: 0.41 [0.15, 0.97]), whilst low VT ventilation with moderate PEEP was superior to CMV in reducing the risk of pneumonia (OR 0.46 [95% CrI: 0.15, 0.94]).
Conclusions: The combination of low VT ventilation and moderate-to-high PEEP (≥5 cm H2O) seems to confer lung protection in surgical patients undergoing general anaesthesia.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：王贵龙 编辑：冯玉蓉 审校：王贵龙