高呼气末正压通气可有效改善急性呼吸窘迫征患者的氧合功能：系统评价与meta分析
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Higher PEEP improves outcomes in ARDS patients with clinically objective positive oxygenation response to PEEP: a systematic review and meta-analysis
背景与目的
急性呼吸窘迫综合征（ARDS）患者的死亡率仍然很高，这些患者需要包括高呼气末正压（PEEP）的机械通气策略。那么高PEEP是否能够改善ARDS患者的预后？特别是在PEEP下氧合反应有所改善的患者。本研究旨在探讨高PEEP对ARDS患者的影响。
方 法
我们检索了MEDLINE、CENTRAL、EMBASE、CINAHL和Web of Science等数据库中1990年1月到2017年12月相关的随机对照试验（RCT），采用Cochrane推荐的方法对PEEP对成年ARDS患者的影响进行了Meta分析。
结 果
共纳入来自9个随机对照试验（RCT）的3612例患者，高PEEP组1794例，低PEEP组1818例；高PEEP组与低PEEP组住院死亡率无显著差异（RR=0.92；95%CI，0.79～1.07；P=0.26）；28天死亡率（RR=0.88；95%CI，0.72至1.07；P=0.19）和ICU死亡率（RR=0.83；95%CI，0.65至1.07；P=0.15）两组间也无统计学差异；高PEEP组与低PEEP组气压伤的危险性无显著差异（RR=1.24；95%CI，0.74～2.09，P=0.41）；在ARDS患者亚组分析中（来自6个RCT）， PEEP增加，高PEEP组对氧合改善作出反应的患者医院病死率(RR=0.83;95%CI 0.69～0.98;P=0.03)、ICU病死率显著降低(RR=0.74;95%CI,0.56～0.98;P=0.04),但28d病死率无明显下降(RR=0.83;95%CI,0.67～1.01;P=0.07)；与PEEP水平低于10cmH2O（来自6个RCT）的低PEEP组ARDS患者比较，高PEEP组的ICU死亡率低于相对较低（RR=0.65；95%CI，0.45-0.94；P=0.02）。
结 论
对于可通过增加PEEP而改善氧合反应的ARDS患者，高PEEP可降低死亡率、ICU死亡率和28天死亡率，且高PEEP不增加气压伤的风险。
原始文献摘要
Guo L, Xie J, Huang Y, et al. Higher PEEP improves outcomes in ARDS patients with clinically objective positive oxygenation response to PEEP: a systematic review and meta-analysis[J]. BMC anesthesiology, 2018.
Background: Mortality in patients with acute respiratory distress syndrome (ARDS) remains high. These patients require mechanical ventilation strategies that include high positive end-expiratory pressure (PEEP). It remains controversial whether high PEEP can improve outcomes for ARDS patients, especially patients who show improvement in oxygenation in response to PEEP. In this meta-analysis, we aimed to evaluate the effects of high PEEP on ARDS patients.
Methods: We electronically searched randomized controlled trials (RCTs) reported in the MEDLINE, CENTRAL,EMBASE, CINAHL and Web of Science databases from January 1990 to December 2017. Meta-analyses of the effects of PEEP on survival in adults with ARDS were conducted using the methods recommended by the Cochrane
Collaboration.
Results: A total of 3612 patients from nine randomized controlled trials (RCTs) were included. There were 1794 and 1818 patients in the high and low PEEP groups, respectively. Hospital mortality showed no significant difference between the high and low PEEP groups (RR = 0.92; 95% CI, 0.79 to 1.07; P = 0.26). Similar results were found for 28-d mortality (RR = 0.88; 95% CI, 0.72 to 1.07; P = 0.19) and ICU mortality (RR = 0.83; 95% CI, 0.65 to 1.07; P = 0.15). The risk of clinically objectified barotrauma was not significantly different between the high and low PEEP groups (RR = 1.24; 95% CI, 0.74 to 2.09, P =0.41). In the subgroup of ARDS patients who responded to increased PEEP by improved oxygenation (from 6 RCTs), high PEEP significantly reduced hospital mortality (RR = 0.83; 95% CI 0.69 to 0.98; P = 0.03), ICU mortality (RR = 0.74; 95% CI, 0.56 to 0.98; P = 0.04),but the 28-d mortality was not decreased(RR = 0.83; 95% CI, 0.67 to 1.01; P = 0.07). For ARDS patients in the low PEEP group who received a PEEP level lower than 10 cmH2O (from 6 RCTs), ICU mortality was lower in the high PEEP group than the low PEEP group (RR = 0.65; 95% CI, 0.45 to 0.94; P =0.02).
Conclusions: For ARDS patients who responded to increased PEEP by improved oxygenation, high PEEP could reduce hospital mortality, ICU mortality and 28-d mortality. High PEEP does not increase the risk of clinically objectified barotrauma.
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贵州医科大学高鸿教授课题组
编辑：王贵龙 审校：李华宇