机械通气患者吸气肌训练效果的Meta分析

doi:10.3761/j.issn.0254-1769.2020.01.025

摘要/Abstract

摘要：

目的评价吸气肌训练在机械通气患者中的应用效果。方法计算机检索Cochrane Library、PubMed、Web of Science、Embase、中国生物医学文献数据库、中国学术期刊全文数据库和万方数据库中有关机械通气患者吸气肌训练效果的随机对照试验,采用RevMan 5.3软件进行Meta分析。结果最终纳入21篇文献,共1 014例患者。Meta分析结果显示,吸气肌训练能有效改善机械通气患者训练后最大吸气压[WMD=7.98,95%CI（7.22,8.73）,P<0.001]、训练前后最大吸气压差值[WMD=5.76,95%CI（4.23,7.29）,P<0.001]、动脉氧分压[WMD=9.55,95%CI（4.00,15.10）,P<0.001]和动脉血氧饱和度[WMD=2.00,95%CI（1.15,2.85）,P<0.001];缩短患者机械通气时间[SMD=-0.33,95%CI（-0.52,-0.14）,P<0.001]、脱机时间[SMD=-1.00,95%CI（-1.51,-0.48）,P<0.001]和ICU住院时间[WMD=-3.46,95%CI（-5.36,-1.56）,P<0.001];并降低病死率[RR=0.55,95%CI（0.33,0.91）,P=0.02],差异均具有统计学意义（P<0.05）。结论吸气肌训练能有效改善机械通气患者最大吸气压,提高呼吸肌肌力与耐力,改善患者氧合状态,从而缩短机械通气时间、脱机时间和ICU住院时间,并降低病死率。

关键词: 吸气肌训练, 机械通气, 重症监护, 随机对照试验, Meta分析

Abstract:

Objective To evaluate the effectiveness of inspiratory muscle training（IMT） among patients with mechanical ventilation（MV）. Methods We searched databases including Cochrane Library,PubMed,Web of Science,EMbase,CBM,CNKI and Wanfang Data. We used RevMan 5.3 software to conduct meta-analysis. Results A total of 21 RCTs including 1,014 patients were included in this meta-analysis. The meta-analysis showed that IMT could improve terminal maximal inspiratory pressure（MIP）,difference MIP,PaO₂ and SaO₂[WMD and 95%CI were 7.98（7.22,8.73）;5.76（4.23,7.29）;9.55（4.00,15.10）;2.00（1.15,2.85）];decrease duration of MV,duration of weaning and length of stay in ICU[SMD/WMD and 95%CI were -0.33（-0.52,-0.14）;-0.99（-1.50,-0.48）;-3.46（-5.36,-1.56）],and reduce mortality[RR=0.55,95%CI（0.33,0.91）,P=0.02]. Conclusion IMT was effective in improving MIP and respiratory muscle strength and endurance,improving patients’ oxygenation status,and reducing duration of MV,weaning,length of stay in ICU,and mortality.

Key words: Inspiratory Muscle Training, Mechanical Ventilation, Intensive Care, Randomized Controlled Trial, Meta-Analysis

姚丽, 杨琳, 杨丽平, 张志刚, 张彩云, 丁楠楠, 田金徽. 机械通气患者吸气肌训练效果的Meta分析[J]. 中华护理杂志, 2020, 55(1): 141-147.

YAO Li, YANG Lin, YANG Liping, ZHANG Zhigang, ZHANG Caiyun, DING Nannan, TIAN Jinhui. Inspiratory muscle training in patients with mechanical ventilation：a meta-analysis[J]. Chinese Journal of Nursing, 2020, 55(1): 141-147.

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参考文献 41

[1]	Pu L, Zhu B, Jiang L , et al. Weaning critically ill patients from mechanical ventilation:a prospective cohort study[J]. J Crit Care, 2015,30(4):7-13.
[2]	Chang AT, Boots RJ, Brown MG , et al. Reduced inspiratory mu-scle endurance following successful weaning from prolonged mechanical ventilation[J]. Chest, 2005,128(2):553-559.
[3]	Bissett B, Leditschke IA, Green M , et al. Inspiratory muscle trai-ning for intensive care patients:a multidisciplinary practical guide for clinicians[J]. Aust Crit Care, 2019,32(3):249-255.
[4]	Vorona S, Sabatini U, Al-Maqbali S , et al. Inspiratory muscle rehabilitation in critically ill adults:a systematic review and meta-analysis[J]. Ann Am Thorac Soc, 2018,15(6):735-744.
[5]	Elkins M, Dentice R . Inspiratory muscle training facilitates wea-ning from mechanical ventilation among patients in the intensive care unit:a systematic review[J]. J Physiother, 2015,61(3):125-134.
[6]	Liu W, Mu X, Wang X , et al. Effects of comprehensive pulmonary rehabilitation therapy on pulmonary functions and blood gas indexes of patients with severe pneumonia[J]. Exp Ther Med, 2018,16(3):1953-1957.
[7]	Girard TD, Alhazzani W, Kress JP , et al. An Official American Thoracic Society/American College of Chest Physicians clinical practice guideline:liberation from mechanical ventilation in critically ill adults. Rehabilitation protocols,ventilator liberation protocols,and cuff leak tests[J]. Am J Respir Crit Care Med, 2017,195(1):120-133.
[8]	Higgins JP, Green S . Cochrane handbook for systematic reviews of interventions 4.2.6. 2006[S]. The Cochrane Collaboration, 2006.
[9]	刘敏, 王兆, 笪苗 , 等. AECOPD机械通气患者膈肌超声监测下吸气肌锻炼研究[J]. 护理学杂志, 2018,33(19):18-21.
[10]	Sandoval MLM, Casas QIC, Wilches LEC , et al. Efficacy of respiratory muscle training in weaning of mechanical ventilation in patients with mechanical ventilation for 48 hours or more:a randomized controlled clinical trial[J]. Med Intensiva, 2019,43(2):79-89.
[11]	Tonella RM, Ratti LDSR, Delazari LEB , et al. Inspiratory muscle training in the intensive care unit:a new perspective[J]. J Clin Med Res, 2017,9(11):929-934.
[12]	Melo PF, Da Silva V, Vieira L , et al. High intensity inspiratory muscle training in patients with traumatic brain injury under mechanical ventilation:preliminary results of a randomized controlled trial[J]. Am J Resp Crit Care Med, 2017,195:A2749.
[13]	Guimarães BL, de Souza L, Guimaraes F , et al. Use of a new isokinetic device oriented by software for inspiratory muscle training in prolonged weaning[J]. Crit Care, 2017,21(2):40.
[14]	Nepomuceno BRVJR, Barreto MS, Almeida NC , et al. Safety and efficacy of inspiratory muscle training for preventing adverse outcomes in patients at risk of prolonged hospitalisation[J]. Trials, 2017,18(1):626.
[15]	Bissett BM, Leditschke IA, Neeman T , et al. Inspiratory muscle training to enhance recovery from mechanical ventilation:a randomised trial[J]. Thorax, 2016,71(9):812-819.
[16]	Özyürek S, Malkoç M, Günerli A , et al. Inpatient inspiratory muscle training after upper abdominal surgery[J]. Eur Respir J, 2014,44:3663.
[17]	Ibrahiem AAA, Mohamed AR, Elbasiouny S , et al. Effect of respiratory muscles training in addition to standard chest physiotherapy on mechanically ventilated patients[J]. J Med Res Practice, 2014,3(3):52-58.
[18]	Dixit A, Prakash S . Effects of threshold inspiratory muscle training versus conventional physiotherapy on the weaning period of mechanically ventilated patients:a comparative study[J]. Int J Physiother Res, 2014,2(2):424-428.
[19]	Elbouhy MS, Abdelhalim HA, Hashem AMA . Effect of respiratory muscles training in weaning of mechanically ventilated COPD patients[J]. Egyptian J Chest Dis Tuberculosis, 2014,63(3):679-687.
[20]	Shimizu JM, Manzano RM, Quitério RJ , et al. Determinant factors for mortality of patients receiving mechanical ventilation and effects of a protocol muscle training in weaning[J]. MTP Rehab J, 2014,12:136-142.
[21]	Mohamed AR, Basiouny HMS, Salem NM . Response of mechanically ventilated respiratory failure patients to respiratory muscles training[J]. Med J Cairo Univ, 2014,82:19-24.
[22]	Pascotini FDS, Denardi C, Nunes GO , et al. Respiratory muscle training in patients weaning from mechanical ventilation[J]. ABCS Health Sci, 2014,39:12-16.
[23]	Condessa RL, Brauner JS, Saul AL , et al. Inspiratory muscle training did not accelerate weaning from mechanical ventilation but did improve tidal volume and maximal respiratory pressures:a randomised trial[J]. J Physiother, 2013,59(2):101-107.
[24]	Chang MY, Chang LY, Huang YC , et al. Chair-sitting exercise intervention does not improve respiratory muscle function in mechanically ventilated intensive care unit patients[J]. Respir Care, 2011,56:1533-1538.
[25]	Martin AD, Smith BK, Davenport PD , et al. Inspiratory muscle strength training improves weaning outcome in failure to wean patients:a randomized trial[J]. Crit Care, 2011,15:R84.
[26]	Cader SA, Vale RG S, Castro JC , et al. Inspiratory muscle train-ing improves maximal inspiratory pressure and may assist weaning in older intubated patients:a randomised trial[J]. J Physiother, 2010,56(3):171-177.
[27]	Porta R, Vitacca M, Gilè LS , et al. Supported arm training in patients recently weaned from mechanical ventilation[J]. Chest, 2005,128(4):2511-2520.
[28]	Caruso P, Denari SDC, Ruiz SAL , et al. Inspiratory muscle train-ing is ineffective in mechanically ventilated critically ill patients[J]. Clinics, 2005,60(6):479-484.
[29]	Holliday JE, Hyers TM . The reduction of weaning time from mechanical ventilation using tidal volume and relaxation biofeedback[J]. Am Rev Respir Dis, 1990,141(1):1214-1220.
[30]	Efstathiou ID, Mavrou IP, Grigoriadis KE . Correlation between maximum inspiratory pressure and hand-grip force in healthy young and middle-age individuals[J]. Respir Care, 2016,61(7):925-929.
[31]	Moodie L, Reeve J, Elkins M . Inspiratory muscle training increases inspiratory muscle strength in patients weaning from mechanical ventilation:a systematic review[J]. J Physiother, 2011,57(4):213-221.
[32]	王翠, 张楠, 郭敏 , 等. 慢性心力衰竭患者吸气肌训练效果的Meta分析[J]. 中华护理杂志, 2018,53(8):932-938.
[33]	查倩倩, 钮美娥, 赵媛媛 , 等. 胃食管反流病患者进行呼吸训练的研究进展[J]. 中华护理杂志, 2018,53(10):1259-1263.
[34]	Gosselink R, De Vos J, van den Heuvel SP, , et al. Impact of inspiratory muscle training in patients with COPD:what is the evidence[J]. Eur Respir J, 2011,37(2):416-425.
[35]	Nava S, Fasano L . Inspiratory muscle training in difficult to wean patients:work it harder,make it better,do it faster,makes us stronger[J]. Crit Care, 2011,15(2):153.
[36]	Bonnevie T, Villiot-Danger JC, Gravier FE , et al. Inspiratory muscle training is used in some intensive care units,but many training methods have uncertain efficacy:a survey of French physiotherapists[J]. J Physiother, 2015,61(4):204-209.
[37]	李珂, 李楠, 邓兰芬 . 机械通气患者吸痰致低氧血症的护理干预研究进展[J]. 中华护理杂志, 2011,46(6):630-632.
[38]	Nava S . Rehabilitation of patients admitted to a respiratory intensive care unit[J]. Arch Phys Med Rehabil, 1998,79(7):849-854.
[39]	Downey AE, Chenoweth LM, Townsend DK , et al. Effects of ins-piratory muscle training on exercise responses in normoxia and hypoxia[J]. Respir Physiol Neurobiol, 2007,156(2):137-146.
[40]	林传焕, 刘毅君, 谷欣 . 气道闭合压、最大吸气压和呼吸浅快指数对慢阻肺患者撤机的预测价值[J]. 临床肺科杂志, 2016,21(12):2240-2243.
[41]	Cordeiro de Souza L, Campos JF, Daher LP , et al. Mechanical ventilation weaning in inclusion body myositis:feasibility of isokinetic inspiratory muscle training as an adjunct therapy[J]. Case Rep Crit Care, 2014: 902541.