气管切开时机对长期机械通气患者预后影响的meta分析

摘要

Objective To evaluate the effect of timing of tracheotomy on the prognosis of prolonged mechanically ventilated patients. Methods Randomized controlled trials (RCTs) that studied the effect of timing of tracheotomy on the prognosis of prolonged mechanically ventilated patients were searched from Pubmed, Embase, The Cochrane Library, CBM during January 1990 to June 2010. The quality of the RCTs was evaluated. Meta-analysis of timing of tracheotomy on the prognosis of prolonged mechanically ventilated patients were conducted using the methods recommended by the Cochrane Collaboration. Definition of early tracheotomy was the patients performed tracheotomy during 10 days after admission to hospital or ICU,mechanical ventilation or intubation. Late tracheotomy was defined tracheotomy performed beyond 10 days of admission to hospital or ICU, mechanical ventilation or intubation; or those mechanically ventilated through intubation all the time. Results Eight hundred and twenty eight patients, 411 in early tracheotomy group and 417 in late tracheotomy group, from 6 RCTs were included in the analysis of data. The meta-analysis showed that early tracheotomy could reduce mortality of patients ( RR:0. 81,95% CI:0. 66-0.99 ,P=0.04);but it didn't significantly alter the incidence of pneumonia (RR: 0. 89,95% CI:0.68-1.17, P=0.41),mechanical ventilation days (mean difference: -2. 19,95% CI: -9. 86-5.49,P =0. 58) and length of ICU stay (mean difference:-5.65,95%CI:-17.11-5.81,P =0.33).Conclusions In critically ill adult patients who require prolonged mechanical ventilation, early tracheotomy performed at an earlier stage reduces the mortality, but doesn't reduce the incidence of pneumonia and shorten the mechanical ventilation days and ICU length of stay. But more high quality RCTs are required to confirm it.%目的 评价气管切开时机对长期机械通气患者预后的影响.方法 通过计算机检索Pubmed、Embase、The Cochrane Library数据库和中国生物医学文献数据库(CBM)并联合手工检索,收集1990年1月至2010年6月关于气管切开时机对长期机械通气患者预后影响的随机对照研究(RCT),并对收集的RCT进行评价,按Cochrane协作网推荐的方法对早期气管切开和晚期气管切开对长期机械通气患者预后的影响作meta分析,采用Review Manager(RevMan)5.0软件进行统计学分析.将早期气管切开组定义为入院或入住ICU后气管插管或机械通气后＜10 d;晚期气管切开组定义为入院或入住ICU后气管插管或机械通气后＞10 d(包括继续气管插管机械通气者或者气管切开者).结果 经过筛查最终共纳入6项RCT,总病例数828例,其中早期气管切开组411例,晚期气管切开组417例.经过统计分析显示,与晚期气管切开组相比,早期气管切开可降低长期机械通气患者的病死率(RR:0.81,95%CI:0.66～0.99,P=0.04),但不降低长期机械通气患者的肺炎发生率(RR:0.89,95%CI:0.68～1.17,P=0.41),机械通气时间(平均差为-2.19,95%CI:-9.86～5.49,P=0.58)和ICU住院时间(平均差为-5.65,95%CI:-17.11～5.81,P=0.33).结论 早期气管切开可能降低长期机械通气患者的病死率,对长期机械通气患者的肺炎发生率、机械通气时间和ICU住院时间无改善,但仍需要进一步证实.