预防性肠外给与类固醇预防成年人拔管后呼吸道并发症:随机安慰剂对照实验的meta分析

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Prophylactic administration of parenteral steroids for preventing airway complications after extubation in adults:meta-analysis of randomised placebo controlled trials

背景与目的

为了确定类固醇是否能有效地预防拔管喉头水肿,并减少对重症患者后续重新插管的需要。

方  法

选择数据库 PubMed, Cochrane Controlled Trials Register, Web of Science,  Embase选择标准:成人使用肠外类固醇与安慰剂预防拔管后并发症的随机安慰剂对照实验。评价方法:搜索、纳入和排除标准的应用、数据提取和方法学质量的评估,独立按一式两份的形式执行。95%置信区间的让步比、风险差异和需要处理的数字进行计算汇总。主要指标检测:首要指标:拔管后喉头水肿。次要指标:由于喉头水肿的二次插管。

结  果

纳入了六个实验(n = 1923)。与安慰剂相比,在计划拔管前,给与类固醇能降低喉头水肿比率 (0.38,95%CI,0.17~0.85)和随后的二次插管(0.29,0.15-0.58),相应的风险差异为0.10(0.12~0.07;需要治疗的病人分别有10人)和0.02(0.04~0.01,需要治疗的50人);亚组分析表明,多剂量类固醇对喉头水肿 (0.14;0.08~0.23)以及随后的二次插管率(0.19;0.07~0.50的发生有显著的积极影响,风险差异为0.19(0.24~0.15;5)和0.04(0.07~0.02;25)。在单一剂量下,只有一种有益趋势,置信区间包括1。没有发现与类固醇有关的副作用。

结  论

在计划拔管前,预防性肠外给与多剂量类固醇可以减少成人拔管后喉头水肿的发生率以及二次插管率,且几乎没有不良反应。

原始文献摘要

Tao F, Gang W, Bing M, et al. Prophylactic administration of parenteral steroids for preventing airway complications after extubation in adults: meta-analysis of randomised placebo controlled trials[J]. Bmj, 2008, 337(7678):a1841.

Objective :To determine whether steroids are effective in preventing laryngeal oedema after extubation and reducing the need for subsequent reintubation in critically ill adults.

Design: Meta-analysis.

Data sources: PubMed, Cochrane Controlled Trials Register, Web of Science, and Embase with no limitation on language, study year, or publication status.

Selection criteria :Randomised placebo controlled trials in which parenteral steroids were compared with placebo for preventing complications after extubation in adults.

Review methods :Search, application of inclusion and exclusion criteria, data extraction, and assessment of methodological quality, independently performed in duplicate. Odds ratios with 95% confidence intervals, risk difference, and number needed to treat were calculated and pooled.

Main outcome measures: Primary outcome: laryngeal oedema after extubation. Secondary outcome: subsequent reintubation because of laryngeal oedema.

Results:Six trials (n=1923)were identified. Comparedwith placebo, steroids given before planned extubation decreased the odds ratio for laryngeal oedema (0.38, 95% confidence interval 0.17 to 0.85) and subsequent reintubation (0.29, 0.15 to 0.58), corresponding with a risk difference of −0.10 (−0.12 to −0.07; number needed to treat 10) and −0.02 (−0.04 to −0.01; 50), respectively. Subgroup analyses indicated that a multidose regimen of steroids had marked positive effects on the occurrence of laryngeal oedema (0.14; 0.08 to 0.23) and on the rate of subsequent reintubation (0.19; 0.07 to 0.50), with a risk difference of−0.19 (−0.24 to−0.15; 5) and−0.04 (−0.07 to −0.02; 25). In single doses there was only a trend towards benefit, with the confidence interval including 1. Side effects related to steroids were not found.

Conclusion: Prophylactic administration of steroids in multidose regimens before planned extubation reducesthe incidence of laryngeal oedema after extubation and the consequent reintubation rate in adults, with few adverse events.

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