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VT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VT通气策略与常规机械通气（CMV）或两种低VT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VT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VT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VT通气策略优于CMV (OR 0.46 [95% CrI: 0.15, 0.94])。

结论：低VT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 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 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 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.

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