预防术后肺部并发症的围术期通气策略

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预防术后肺部并发症的围术期通气策略

翻译：佟睿  编辑：冯玉蓉  审校：曹莹

背景：对于手术患者肺保护通气策略的争论一直都在进行中。有证据表明，使用低潮气量V_T可以改善临床预后。然而，低潮气量通气中最佳水平PEEP及肺复张手段（RM）策略仍不明晰。

方法：搜索电子数据库以筛选对比手术患者低V_T通气策略与常规机械通气（CMV）或两种低V_T通气策略之间差异的文献。主要结果为术后肺部并发症（PPCs）。次要结果为肺不张、肺炎、急性呼吸窘迫综合征和短期死亡率。使用WinBUGS进行贝叶斯网络meta分析，并估计优势比（ORs）和相应的95%可信区间（CrIs）。

结果：与CMV相比，采用从中到高PEEP的低V_T通气策略能够降低PPCs的风险（中PEEP[5~8 cm H₂O]: OR 0.50[95% CrI: 0.28, 0.89]; 中PEEP＋RMs: 0.39[0.79,0.78]; 高PEEP[≥9 cm H₂O]＋RMs: 0.34[0.14, 0.79]）。采用从中到高PEEP的低V_T通气策略也能够明确降低肺不张风险 (中PEEP＋RMs: OR 0.36 [95% CrI: 0.16, 0.87]; 高PEEP＋RMs: 0.41 [0.15, 0.97]。同样在降低肺炎风险上，采用从中到高PEEP的低V_T通气策略优于CMV (OR 0.46 [95% CrI: 0.15, 0.94])。

结论：低V_T通气联合从中到高PEEP（≥5 cm H₂O）通气策略似乎对接受全身麻醉的手术患者具有肺保护作用。

原始文献来源：Deng QW, Tan WC, Zhao BC, et al. Intraoperative ventilation strategies to prevent postoperative pulmonary complications: a network meta-analysis of randomised controlled trials.[J].Br J Anaesth 2020 Mar ; 124 (3): 324-335.

Intraoperative ventilation strategies to prevent postoperative pulmonary complications: a network meta-analysis of randomised controlled trials

Abstract

Background: The debate on lung-protective ventilation strategies for surgical patients is ongoing. Evidence suggests that the use of low tidal volume V_T improves clinical outcomes. However, the optimal levels of PEEP and recruitment manoeuvre (RM) strategies incorporated into low V_T ventilation remain unclear.

Methods: Several electronic databases were searched to identify RCTs that focused on comparison between low V_T strategy and conventional mechanical ventilation (CMV), or between two different low V_T 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 V_T 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 V_T ventilation with moderate-to-high PEEP and RMs also specifically 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 V_T 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 V_T ventilation and moderate-to-high PEEP (≥ 5 cm H₂O) seems to confer lung protection in surgical patients undergoing general anaesthesia.

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