清醒俯卧位通气在急性低氧性呼吸衰竭患者中应用效果的Meta分析

doi:10.3761/j.issn.0254-1769.2023.13.017

摘要/Abstract

摘要：

目的探讨清醒俯卧位通气策略在急性低氧性呼吸衰竭（acute hypoxemic respiratory failure，AHRF）患者中的应用效果。方法计算机系统检索中国知网、万方数据库、维普数据库、PubMed、Embase、Web of Science、Cochrane Library中关于AHRF患者清醒俯卧位通气的随机对照试验和观察性研究，检索时限为建库至2022年8月，同时追溯纳入文献的参考文献。2名研究者独立按照纳入和排除标准进行文献筛选、资料提取以及质量评价，通过RevMan 5.3软件进行Meta分析。结果最终纳入12篇文献，包括5项随机对照试验和7项队列研究，共2 632例患者。Meta分析结果显示，清醒俯卧位通气组的插管率与常规护理组相比，差异具有统计学意义[RR=0.73，95%CI（0.65，0.82），P<0.001]；病死率[RR=0.87，95%CI（0.74，1.03），P=0.110]、住院时间[MD=-1.05，95%CI（-4.22，2.12），P=0.520]与常规护理组相比，差异无统计学意义。7项研究报告了清醒俯卧位通气继发的不良反应，包括不适（8%~35%）、疼痛（7%~11%）、呕吐（2%~8%）、导管移位（4%~6%）、皮肤破溃（0.4%~4.0%）、低血压（4%）、静脉血栓栓塞（2.3%）、咳嗽（2%）、吸入性肺炎（1.5%）。患者单次俯卧位时间相差较大（1.25~15.00） h。结论清醒俯卧位通气可有效降低AHRF患者的插管率，尚不能减少患者的住院时间，并且对病死率的影响有待进一步验证。患者俯卧位时最常见的不良反应为不适和疼痛，其依从性受到影响。建议未来应开展高质量的研究，旨在强化清醒俯卧位通气护理管理，提高患者依从性，进一步提高治疗的成功率。

关键词: 清醒俯卧位通气, 急性低氧性呼吸衰竭, Meta分析, 循证护理学

Abstract:

Objective To evaluate the effect of awake prone positioning strategy in patients with acute hypoxemic respiratory failure（AHRF）. Methods 7 electric databases including the China National Knowledge Infrastructure（CNKI），Wanfang Database，VIP Database，PubMed，Embase，Web of Science，and Cochrane Library were systematically searched for randomized controlled trials and observations on awake prone positioning in patients with AHRF. The search time limit is from the establishment of the database to August 2022，and the references of the included literature are also traced. 2 researchers independently performed literature screening，data extraction and quality assessment according to the inclusion and exclusion criteria. Meta-analysis was performed by RevMan 5.3 software. Results 12 pieces of the literature were finally included，including 5 randomized controlled trials and 7 cohort studies，with a total of 2 632 patients. The results of Meta-analysis showed that the intubation rate of the awake prone positioning group was significantly different from that of the routine care group[RR=0.73，95%CI （0.65，0.82），P<0.001]；compared with those of the routine care group，the differences of the mortality rate[RR=0.87，95%CI(0.74，1.03), P=0.110] and hospital stay[MD=-1.05，95%CI(-4.22, 2.12),P=0.520] were not statistically significant. The secondary adverse effects to awake prone positioning were reported in 7 studies, including discomfort(8%~35%),pain(7%~11%),vomiting(2%~8%),catheter displacement(4%~6%),skin ulceration(0.4%~4.0%),hypotension(4%),venous thromboembolism(2.3%),cough(2%),and aspiration pneumonia(1.5%). The time range of a single prone position of the patients was quite different(1.25~15.00) h. Conclusion Awake prone positioning can effectively reduce the intubation rate of AHRF patients，but it cannot reduce the hospital stay of patients，and the impact on mortality needs further research and verification. Intolerance and pain were the most common adverse reactions when patients were in the prone position，affecting their compliance. Therefore，it is suggested that high-quality research should be carried out in the future，aiming at strengthening nursing management of awake prone positioning，improving patient compliance，and further improving the success rate of treatment.

Key words: Awake Prone Positioning, Acute Hypoxemic Respiratory Failure, Meta-Analysis, Evidence-based Nursing

李丝静, 江智霞, 杨晓玲, 袁晓丽, 谢光辉, 罗娟, 董俊兰. 清醒俯卧位通气在急性低氧性呼吸衰竭患者中应用效果的Meta分析[J]. 中华护理杂志, 2023, 58(13): 1640-1647.

LI Sijing, JIANG Zhixia, YANG Xiaoling, YUAN Xiaoli, XIE Guanghui, LUO Juan, DONG Junlan. Effectiveness of awake prone positioning in patients with acute hypoxemic respiratory failure：a Meta-analysis[J]. Chinese Journal of Nursing, 2023, 58(13): 1640-1647.

图/表 4

图1 文献筛选流程图

Figure 1 Flow chart of literature screening

表1 纳入文献的基本特征（n=12）

Table 1 Basic characteristics of included literature（n=12）

表2 随机对照试验的方法学质量评价结果（n=5）

Table 2 Methodological quality assessment results of randomized controlled trials（n=5）

表3 队列研究的方法学质量评价结果（n=7）

Table 3 Methodological quality evaluation results of cohort studies（n=7）

参考文献 36

[1]	邱小松, 吕兰欣, 薛婷, 等. 急性低氧性呼吸衰竭患者气管插管后低血压风险的多因素分析与预后研究[J]. 中国急救医学, 2020, 40(2):97-101.
	Qiu XS, Lü LX, Xue T, et al. Analysis of risk factors and prognosis of postintubation hypotension in the patients with acute hypoxic respiratory failure[J]. Chin J Crit Care Med, 2020, 40(2):97-101.
[2]	Stefan MS, Shieh MS, Pekow PS, et al. Epidemiology and outcomes of acute respiratory failure in the United States,2001 to 2009:a national survey[J]. J Hosp Med, 2013, 8(2):76-82. DOI URL
[3]	Bryan AC. Conference on the scientific basis of respiratory the-rapy. Pulmonary physiotherapy in the pediatric age group. Com-ments of a devil’s advocate[J]. Am Rev Respir Dis, 1974, 110(6 Pt 2):143-144.
[4]	Cornejo RA, Díaz JC, Tobar EA, et al. Effects of prone positioning on lung protection in patients with acute respiratory distress syndrome[J]. Am J Respir Crit Care Med, 2013, 188(4):440-448. DOI URL
[5]	Richter T, Bellani G, Scott Harris R, et al. Effect of prone position on regional shunt,aeration,and perfusion in experimental acute lung injury[J]. Am J Respir Crit Care Med, 2005, 172(4):480-487. DOI URL
[6]	Scaravilli V, Grasselli G, Castagna L, et al. Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure:a retrospective study[J]. J Crit Care, 2015, 30(6):1390-1394. DOI PMID
[7]	Feltracco P, Serra E, Barbieri S, et al. Non-invasive ventilation in prone position for refractory hypoxemia after bilateral lung transplantation[J]. Clin Transplant, 2009, 23(5):748-750. DOI PMID
[8]	Kang H, Gu XQ, Tong ZH. Effect of awake prone positioning in non-intubated COVID-19 patients with acute hypoxemic respiratory failure:a systematic review and meta-analysis[J]. J In-tensive Care Med, 2022, 37(11):1493-1503.
[9]	Beran A, Mhanna M, Srour O, et al. Effect of prone positioning on clinical outcomes of non-intubated subjects with COVID-19[J]. Respir Care. 2022, 67(4):471-479. DOI URL
[10]	Tan W, Xu DY, Xu MJ, et al. The efficacy and tolerance of prone positioning in non-intubation patients with acute hypoxemic respiratory failure and ARDS:a meta-analysis[J]. Ther Adv Respir Dis, 2021, 15:17534666211009407.
[11]	Fusi C, Bulleri E, Villa M, et al. Awake prone positioning in nonintubated patients with acute hypoxemic respiratory failure[J]. Crit Care Nurse, 2023, 43(1):31-41. DOI PMID
[12]	Dement’eva II. Monitoring of lactate level and oxygen status for diagnosis and correction of hypoxia in critically ill patients (a lecture)[J]. Klin Lab Diagn, 2003(3):25-32.
[13]	Higgins JPT, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials[J]. BMJ, 2011, 343(18):d5928. DOI URL
[14]	Stang A. Critical evaluation of the Newcastle-Ottawa Scale for the assessment of the quality of nonrandomized studies in meta-analyses[J]. Eur J Epidemiol, 2010, 25(9):603-605. DOI PMID
[15]	张勤芹, 唐诚, 缪翠维, 等. 早期清醒俯卧位联合经鼻高流量氧疗对轻中度ARDS患者的研究[J]. 临床肺科杂志, 2022, 27(6):858-861.
	Zhang QQ, Tang C, Miao CW, et al. Study of early awake prone position combined with high-flow nasal cannula for patients with mild to moderate ARDS[J]. J Clin Pulm Med, 2022, 27(6):858-861.
[16]	Fralick M, Colacci M, Munshi L, et al. Prone positioning of patients with moderate hypoxaemia due to covid-19:multicentre pragmatic randomised trial(COVID-PRONE)[J]. BMJ, 2022, 376:e068585.
[17]	Jayakumar D, Ramachandran Dnb P, Rabindrarajan Dnb E, et al. Standard care versus awake prone position in adult nonintubated patients with acute hypoxemic respiratory failure secondary to COVID-19 infection:a multicenter feasibility randomized controlled trial[J]. J Intensive Care Med, 2021, 36(8):918-924. DOI URL
[18]	Ehrmann S, Li J, Ibarra-Estrada M, et al. Awake prone posi-tioning for COVID-19 acute hypoxaemic respiratory failure:a randomised,controlled,multinational,open-label meta-trial[J]. Lancet Respir Med, 2021, 9(12):1387-1395. DOI URL
[19]	Ibarra-Estrada M, Li J, Pavlov I, et al. Factors for success of awake prone positioning in patients with COVID-19-induced acute hypoxemic respiratory failure:analysis of a randomized controlled trial[J]. Crit Care, 2022, 26(1):84. DOI
[20]	Aisa T, Hassan T, Khan E, et al. Efficacy and feasibility of awake proning in patients with COVID-19-related acute hypoxemic respiratory failure:an observational,prospective study[J]. Ir J Med Sci, 2023, 192(2):811-815. DOI
[21]	Tonelli R, Pisani L, Tabbì L, et al. Early awake proning in critical and severe COVID-19 patients undergoing noninvasive respiratory support:a retrospective multicenter cohort study[J]. Pulmonology, 2022, 28(3):181-192. DOI URL
[22]	Jouffroy R, Darmon M, Isnard F, et al. Impact of prone position in non-intubated spontaneously breathing patients admitted to the ICU for severe acute respiratory failure due to COVID-19[J]. J Crit Care, 2021, 64:199-204. DOI PMID
[23]	Dubosh NM, Wong ML, Grossestreuer AV, et al. Early,awake proning in emergency department patients with COVID-19[J]. Am J Emerg Med, 2021, 46:640-645. DOI URL
[24]	Fazzini B, Fowler AJ, Zolfaghari P. Effectiveness of prone position in spontaneously breathing patients with COVID-19:a prospective cohort study[J]. J Intensive Care Soc, 2022, 23(3):362-365. DOI URL
[25]	Coppo A, Bellani G, Winterton D, et al. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID):a prospective cohort study[J]. Lancet Respir Med, 2020, 8(8):765-774. DOI PMID
[26]	Solverson K, Weatherald J, Parhar KKS. Tolerability and safety of awake prone positioning COVID-19 patients with severe hypoxemic respiratory failure[J]. J Can D’anesthesie, 2021, 68(1):64-70.
[27]	Andrea B, Adriano B. Prone positioning in severe acute hy-poxemic respiratory failure in the emergency ward[J]. Emerg Care J, 2018, 14(1):22-23.
[28]	Paul V, Patel S, Royse M, et al. Proning in non-intubated(PINI) in times of COVID-19:case series and a review[J]. J Intensive Care Med, 2020, 35(8):818-824. DOI URL
[29]	侯锦, 李奇, 李尊柱, 等. 俯卧位通气患者肠内营养安全性和有效性的Meta分析[J]. 中华护理杂志, 2022, 57(17):2149-2155. DOI
	Hou J, Li Q, Li ZZ, et al. Efficacy and safety of enteral nutrition in patients with prone position ventilation:a meta-analysis[J]. Chin J Nurs, 2022, 57(17):2149-2155.
[30]	上海市新型冠状病毒肺炎临床救治专家组. 新型冠状病毒肺炎患者俯卧位治疗上海专家建议[J]. 中华传染病杂志, 2022, 40(9):513-521.
	Shanghai Expert Group for the Clinical Treatment of Novel Coronavirus Pneumonia. Shanghai expert’s recommendations of prone position therapy in coronavirus disease 2019[J]. Chin J Infect Dis, 2022, 40(9):513-521.
[31]	Li J, Luo J, Pavlov I, et al. Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure:a systematic review and meta-analysis[J]. Lancet Respir Med, 2022, 10(6):573-583. DOI URL
[32]	蒋燕, 陆叶, 蒋旭琴, 等. 成人急性呼吸窘迫综合征患者俯卧位通气管理的最佳证据总结[J]. 中华护理杂志, 2022, 57(15):1878-1885. DOI
	Jiang Y, Lu Y, Jiang XQ, et al. Best evidence summary for prone ventilation management in adults with acute respiratory distress syndrome[J]. Chin J Nurs, 2022, 57(15):1878-1885. DOI
[33]	严重急性低氧性呼吸衰竭急诊治疗专家共识组. 严重急性低氧性呼吸衰竭急诊治疗专家共识[J]. 中华急诊医学杂志, 2018, 27(8):844-849.
	Expert Consensus Group on Emergency Treatment of Severe Acute Hypoxic Respiratory Failure. Expert consensus on emergency treatment of severe acute hypoxic respiratory failure[J]. Chin J Emerg Med, 2018, 27(8):844-849.
[34]	漆敏, 倪忠, 唐永江, 等. 清醒俯卧位通气策略在低氧性呼吸衰竭患者中的应用进展[J]. 中国呼吸与危重监护杂志, 2021, 20(3):215-218.
	Qi M, Ni Z, Tang YJ, et al. Application progress of conscious prone position ventilation strategy in patients with hypoxic respiratory failure[J]. Chin J Respir Crit Care Med, 2021, 20(3):215-218.
[35]	王宇娇, 高岚, 牟静静, 等. 清醒俯卧位通气在急性呼吸窘迫综合征患者中的应用进展[J]. 中华护理杂志, 2023, 58(7):881-884. DOI
	Wang YJ, Gao L, Mu JJ, et al. Application progress of awake self-prone positioning ventilation in patients with acute respiratory distress syndrome[J]. Chin J Nurs, 2023, 58(7):881-884. DOI
[36]	刘飞跃, 邓德贵, 张馨尹, 等. 俯卧位通气患者安全和舒适护理方案的构建[J]. 中华护理杂志, 2023, 58(10):1199-1204. DOI
	Liu FY, Deng DG, Zhang XY, et al. Construction of a safe and comfortable nursing plan for patients with prone position ventilation[J]. Chin J Nurs, 2023, 58(10):1199-1204. DOI