俯卧位通气在体外循环心脏术后低氧血症患者中应用效果的Meta分析

doi:10.3761/j.issn.0254-1769.2022.16.014

摘要/Abstract

摘要： 目的系统评价俯卧位通气在体外循环心脏术后低氧血症患者中的应用效果，为临床进一步探讨该类患者术后有效机械通气体位提供参考依据。方法计算机检索PubMed、Web of Science、Embase、Cochrane Library、CINHAL、中国知网、万方数据库、维普数据库、中国生物医学文献数据库中关于俯卧位通气在体外循环心脏术后低氧血症患者中应用效果的随机对照试验，检索时限为建库至2021年9月。按照纳入和排除标准筛选文献，并进行文献质量评价，采用RevMan 5.4软件进行Meta分析。结果最终纳入9篇文献，共456例患者。Meta分析结果显示，氧合指数比较，当俯卧位通气持续时间≥12 h[MD=57.31，95%CI（35.84，78.77），P<0.001]、开始时间为术后6 h[MD=71.98， 95%CI（64.34，79.61），P<0.001]及采用间断俯卧位通气[MD=37.97，95%CI（18.36，57.58），P=0.001]时，俯卧位通气氧合指数高于仰卧位通气;氧分压比较，当俯卧位通气吸氧浓度>仰卧位通气吸氧浓度时，患者俯卧位通气氧分压高于仰卧位通气，差异具有统计学意义[MD=5.70，95%CI（0.46，10.94），P=0.03];临床结局比较，俯卧位通气的机械通气时间[MD=-56.47，95%CI（-72.62，-40.33），P<0.001]、ICU入住时间[MD=-60.82，95%CI（-76.82，-44.81），P<0.001]及住院时间[MD=-44.36，95%CI（-63.10，-25.62），P<0.001]均低于仰卧位通气。结论俯卧位通气能有效改善体外循环心脏术后低氧血症患者的氧合指数，降低机械通气时间、ICU入住时间及住院时间，而对改善患者氧分压无明显作用。该研究各评价指标存在异质性，且纳入的研究及样本量较少，俯卧位通气持续时间及开始时间不统一，尽管对主要评价指标进行了亚组分析，但仍然无法明确俯卧位通气的最佳持续时间和开始时间。需要更多大样本、高质量的研究进一步评价俯卧位通气对体外循环心脏术后低氧血症患者的应用效果。

关键词: 心脏手术, 体外循环, 呼吸, 人工, 缺氧, 护理, Meta分析, 循证护理学

Abstract:

Objective To systematically evaluate the application effect of prone ventilation in patients with hypoxemia after cardiopulmonary bypass surgery，so as to provide a reference for further discussing the effective mechanical ventilation position of such patients. Methods Pubmed，Web of Science，Embase，Cochrane Library，CENTRAL，CBM，CNKI，Wanfang Data and VIP database were searched from the establishment of databases until September，2021. All the published randomized controlled trials（RCTs） about the effects of prone position ventilation on patients with hypoxemia after cardiac surgery were confirmed by the literature reference citation retrieval. Inclusion and exclusion criteria were used to review and rank the literature. After the evaluation of the quality of included studies，the data was extracted from RCTs and a meta-analysis was conducted by RevMen 5.4. Results 9 RCTs with 456 cases were included. The results of meta-analysis showed that in oxygenation index，the oxygenation index of prone ventilation was higher than that of supine ventilation when the ventilation time（T1） in prone position≥12 h，and the start time（T2） was 6 hours after surgery and the intermittent prone ventilation，and the difference was statistically significant [MD=57.31，95%CI（35.84，78.77），P<0.001]，[MD=71.98，95%CI（64.34，79.61），P<0.001]，[MD=37.97，95%CI（18.36，57.58），P=0.001]. In oxygen partial pressure，when the oxygen concentration（FiO₂） of prone ventilation was lower than that of supine ventilation，the oxygenation index of prone ventilation was higher than that of supine ventilation，and the difference was statistically significant[MD=5.70，95%CI（0.46，10.94），P=0.03]. In clinical outcome，the mechanical ventilation time[MD=-56.47，95%CI（-72.62，-40.33），P<0.001]，ICU stay time[MD=-60.82，95%CI（-76.82，-44.81），P<0.001] and hospital stay time[MD=-44.36，95%CI（-63.10，-25.62），P<0.001] in prone ventilation group were lower than those in supine ventilation group，and the differences were statistically significant. Conclusion The prone position ventilation is effective to improve PaO₂/FiO₂，duration of mechanical ventilation，duration of ICU care，and hospital stays in patients with hypoxemia after cardiac surgery，while it could not effectively improve PaO₂. Despite subgroup analysis of the main indicators，the optimal duration and initiation of prone ventilation remained unclear. Due to the limitations of the quality of included studies，randomized controlled trials with large sample size are needed in the future to evaluate the effects of prone position ventilation on neonatal respiratory distress syndrome.

Key words: Cardiac Surgery, Extracorporeal Circulation, Respiration, Artificial, Anoxia, Nursing Care, Meta-Analysis, Evidence-Based Nursing

姜会, 柏晓玲, 成忠莎, 韦清, 张家兴, 江雪. 俯卧位通气在体外循环心脏术后低氧血症患者中应用效果的Meta分析[J]. 中华护理杂志, 2022, 57(16): 2010-2017.

JIANG Hui, BAI Xiaoling, CHENG Zhongsha, WEI Qing, ZHANG Jiaxing, JIANG Xue. Effect of prone ventilation in patients with hypoxemia after cardiopulmonary bypass surgery:a meta-analysis[J]. Chinese Journal of Nursing, 2022, 57(16): 2010-2017.

图/表 6

表1 纳入文献的基本特征（n=9）

Table 1 Basic characteristics of the included trials（n=9）

表2 纳入文献的方法学质量评价（n=9）

Table 2 Methodological quality assessment for the included trials（n=9）

图1 不同俯卧位通气持续时间及开始时间与仰卧位通气氧合指数的比较注：T1为俯卧位通气持续时间，T2为俯卧位通气开始时间。

Figure 1 Comparison of ventilation duration and start time in different prone position with ventilation oxygenation index in supine position

图2 不同俯卧位通气方式与仰卧位通气氧合指数的比较

Figure 2 Comparison of different ventilation modes in prone position and ventilation oxygenation index in supine position

图3 俯卧位通气与仰卧位通气氧分压的比较注:A为俯卧位通气组FiO2 ;B为仰卧位通气组FiO2。

Figure 3 Comparison of oxygen partial pressure between prone ventilation group and supine ventilation

图4 俯卧位通气与仰卧位通气机械通气时间的比较

Figure 4 Comparison of mechanical ventilation time between prone ventilation group and supine ventilation

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